Table of contents
Original articles
113 Does the addition of LH activity to FSH make gonadotrophins more superior? A systematic review and meta-analysis
Hesham Al-Inany, Amr Wahba, Hatem Abu Hashim, Human Fatemi and Ahmed Abousetta
121 A comparative study between cabergoline, coasting, and step-down regimens in the prevention of severe OHSS and their correlation
with pregnancy rate in intracytoplasmic sperm injection cycles
Hoda Abdelaal, Olfat N. Riade and Mostafa Mahmoud
126 Antral follicular count is a better indicator for the assessment of ovarian reserve
Ahmed Soliman, Sherif Sharkawy, Tamer Abdelmoniem, Hesham Al-Inany and Odette Wahba
133 Comparison between transfrontal and axial three-dimensional ultrasound acquisition in the visualization of midline structures
of the fetal brain
Sherif M.M. Negm and Rasha A. Kamel
138 Glycosylated hemoglobin level at 34 weeks in insulin-controlled diabetic pregnancies, relation to fetal outcome
Hoda Abdelaal, Mohamed A. Kasem, Abdelmeguid Ali and Alaa M. Abd Elazem
142 Evaluation of the atherogenic role of lipoproteins and oxidized low-density lipoprotein in pre-eclampsia
Yasser H. Shaaban, Fatma Aletebi, Manal Helal and Walid Saber
Evidence Based Women’s Health Journal
Vol 2 No 4 November 2012
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Evidence Based Women’s Health Journal
Vol 2 No 4 November 2012
Does the addition of LH activity to FSH make gonadotrophins
more superior? A systematic review and meta-analysisHesham Al-Inanya,b, Amr Wahbaa,b, Hatem Abu Hashima,b, Human Fatemia,b
and Ahmed Abousettaa,b
aDepartment of Obstetrics & Gynecology, Facultyof Medicine, Cairo University, Cairo and bDepartmentof Obstetrics & Gynecology, Faculty of Medicine,Mansoura University, Mansoura, Egypt
Correspondence to Hesham Al-Inany, MD,Abdelhadi St, Manial, 11451 Cairo, EgyptTel: + 011 1222 0298;e-mail: [email protected]
Received 23 April 2012Accepted 12 June 2012
Evidence Based Women’s Health Journal
2012, 2:113–120
Background
The contribution of luteinizing hormone (LH) activity to follicle-stimulating hormone
(FSH) in ovarian stimulation in improving the outcome of IVF/intracytoplasmic sperm
injection (ICSI) has been an area of major debate.
Objective
To systematically locate, review, and analyze the best available evidence on the value of
additional LH activity in ovarian stimulation in IVF and/or ICSI irrespective of the source
of LH.
Design
Systematic review of properly randomized trials comparing FSH only [as recombinant
FSH (recFSH)] vs. LH-containing protocols (derived either from a urinary source or
developed by recombinant technology) in women undergoing IVF and/or ICSI with
desensitization achieved either by long GnRH agonist or GnRH antagonist protocols.
A meticulous search was carried out using electronic databases and hand searches
of the literature.
Results
Thirty-one trials were identified. Only nine trials reported on live birth rate and ovarian
hyperstimulation (OHSS) rates. Pooling of the trials showed that the live birth rate did
not show a statistically significant difference [recFSH (304/1120; 27.14%) vs.
FSH/LH (324/1110; 29.19%) (P = 0.29; odds ratio (OR) = 0.90, 95% confidence
interval (CI) = 0.75–1.09)]. OHSS rates also did not show a significant difference
[recFSH (34/1888; 1.80%) vs. FSH/LH (29/1843; 1.57%) (P = 0.79; OR = 1.08,
95% CI = 0.63–1.83)]. The clinical pregnancy rate significantly favored additional LH
activity [(recFSH (748/2758; 27.1%) vs. FSH/LH (838/2772; 30.2%), P = 0.008;
OR = 0.85 95% CI = 0.76–0.96)], whereas FSH-only protocols (recFSH) yielded a
higher number of retrieved oocytes compared with LH-containing protocols (FSH/LH)
(P = 0.002; mean difference = 1.25, 95% CI = 0.48–2.02).
Conclusion
LH activity is not paramount in ovarian stimulation.
Keywords:
follicle-stimulating hormone, intracytoplasmic sperm injection, in-vitro fertilization,
luteinizing hormone, meta-analysis, ovulation stimulation, systematic review
Evid Based Women Health J 2:113–120& 2012 Evidence Based Women’s Health Journal2090-7265
IntroductionGonadotrophins differ in terms of the source from which
they are extracted (either from urine or from recombinant
DNA technology) and in their formulation [either
containing both follicle-stimulating hormone (FSH) and
luteinizing hormone (LH) or either FSH or LH only].
The composition as well as the source of gonadotrophins
could have an impact on the outcome of IVF. Human
menopausal gonadotropins (hMG) have long been the
classic and principal urinary gonadotrophins used for
ovarian stimulation since the development of ART
technology in the 1970s. It is composed of equal amounts
of FSH and LH (75 U for each per ampoule). However,
since the 1980s, a variety of generations of urinary hMG
have been developed with the intention of eliminating
most or all of the LH content [1]. During the mid-1990s,
recombinant FSH (recFSH) was produced from hamster
ovarian cell cultures and this step was considered
a landmark in the production of gonadotrophins [2].
With the development of such gonadotrophins devoid of
LH activity (namely recFSH and HP-FSH), questions
about the role of adding LH activity to FSH in controlled
ovarian hyperstimulation (COH) in IVF and/or intracyto-
plasmic sperm injection (ICSI) on treatment outcome have
been raised and have been a topic for intense research.
Previous systematic reviews have primarily focused on
comparing the effectiveness of different sources of
gonadotropins. Urinary hMG was compared with recFSH
in two recent meta-analyses, both of which showed
Original article 113
2090-7265 & 2012 Evidence Based Women’s Health Journal DOI: 10.1097/01.EBX.0000419241.48874.fe
a better outcome in terms of live birth rate when hMG
was used for ovarian stimulation compared with recFSH
in the GnRH agonist (GnRHa) long protocol [3,4]. Two
other meta-analyses compared urinary HP-FSH versus
(recFSH) and showed similar pregnancy and live birth
rates, with no difference in the ovarian hyperstimulation
(OHSS) rate [5,6].
However, there is still a need for a better understanding
of the differential effects of different gonadotrophin
preparations and of the impact of the administration of
LH activity during COH.
To extract the evidence on the impact of COH with LH-
containing gonadotrophins on live birth rate and OHSS
rate, the current meta-analysis and systematic review was
carried out to compare FSH-only protocols (recFSH)
with LH-containing protocols irrespective of the source
of gonadotrophins (either hMG or recFSH + recLH) and
irrespective of the protocol of desensitization (either the
GnRHa long protocol or the GnRH antagonist protocol).
Materials and methodsCriteria for considering studies for this review
All published manuscripts and abstracts describing
randomized trials and reporting data that compared
outcomes for women undergoing IVF/ICSI and rando-
mized to undergo ovarian stimulation with FSH-only
protocols (recFSH) or LH-containing protocols (either
hMG or recFSH + recLH) were sought in all languages.
Search strategy for the identification of studies
Meticulous computerized searches (last performedy)
were carried out using MEDLINE (1978 to present),
EMBASE (1980 to present), the Cochrane Central
Register of Controlled Trials (CENTRAL), and the Trial
Register of Controlled Trials (e.g. http://www.controlled-trials.com). Furthermore, the reference lists of all known
primary studies, review articles, citation lists of relevant
publications, abstracts of major scientific meetings (e.g.
ESHRE and ASRM), and included studies were exam-
ined to identify additional relevant citations. Finally,
ongoing and unpublished trials were sought by contacting
experts in the field and commercial entities.
Methods of the review
A standardized data extraction form was developed and
piloted for consistency and completeness. Trials were
considered for inclusion and trial data were extracted.
Data management and statistical analyses were carried
out using the ‘Review Manager 4.3’ (The Cochrane
Collaboration). Individual outcome data were included in
the analysis if they fulfilled the prestated criteria. Where
possible, data were extracted to allow for an intention-to-
treat analysis, defined as including all randomized cycles
in the denominator. If data from the trial reports were
insufficient or missing, the investigators of individual
trials were contacted by e-mail for additional information
to carry out analysis on an intention-to-treat basis.
For the meta-analysis, the number of participants
experiencing the event in each group of the trial was
determined by visual inspection of the outcome tables
and using the w2-test for heterogeneity. In addition, the
I2-test was used to attempt quantification of any apparent
inconsistency. The I2-test is a statistical measure used to
quantify heterogeneity. It describes the percentage of the
variability in effect estimates that is because of hetero-
geneity rather than sampling error (chance). An I2-value
greater than 50% may be considered to represent
substantial heterogeneity.
Types of outcomes measures
The primary outcomes for this systematic review were
live birth rate and OHSS rate. The secondary outcomes
were clinical and ongoing pregnancy rates. In addition,
cycle characteristics (number of oocytes retrieved,
treatment duration, amount of FSH, estradiol on day of
hCG, progesterone on day of hCG, rate of poor
responders) were also evaluated. The trials included
were analyzed for the following characteristics: method of
randomization, presence or absence of blinding to
treatment allocation, quality of allocation concealment,
number of patients randomized, whether an intention-to-
treat analysis was carried out, and the duration, timing,
and location of the study.
Comparison of results
For the meta-analysis, the number of participants
experiencing the event was recorded. Data were ex-
tracted to allow for an intention-to-treat analysis, defined
as including in the denominator all randomized cycles.
Meta-analysis of dichotomous data was carried out using
the Mantel–Haenszel method using a random-effects
model, and the odds ratio (OR) and 95% confidence
interval (CI) were evaluated. Meta-analysis of continuous
data was carried out using the inverse variance method
utilizing a random-effects model. The mean difference
(MD) and 95% CI were evaluated. P values were
presented for further confirmation of the results. The
standardized mean difference was used when multiple
scales were provided (E2). A P value of less than 0.05 was
considered to be significant. The results were pooled
using a fixed-effects model only after confirming that
marked statistical heterogeneity was not present (i.e. the
observed treatment effects in individual trials were not
statistically significantly different from the overall pooled
estimate of the treatment effect).
Participants
Randomized women undergoing IVF/ICSI and COH with
either FSH-only protocols (recFSH) or LH-containing
protocols (either hMG or recFSH + recLH). We ex-
cluded all nonrandomized trials, trials using LH priming
(LH only then FSH only), and trials using HP-FSH
instead of recFSH (as the HP-FSH contains some LH
activity).
114 Evidence Based Women’s Health Journal
ResultsThirty-one randomized-controlled trials (RCTs) were
identified. Twenty-one trials compared the use of recFSH
vs. hMG/HP-hMG whereas 10 RCTs compared recFSH
vs. recFSH + recLH. The method of fertilization used
was either IVF or ICSI. These included trials enrolled
4571 participants, which yielded an adequate power for
meta-analysis.
Nine trials only reported on live birth rate and OHSS
rate. Data were extracted to allow for an intention-to-
treat analysis. Pooling of the included trials showed that
live birth rate was not statistically different between both
groups, although it showed trends toward improvement
with LH-containing protocols [recFSH (304/1120;
27.14%) vs. FSH/LH (324/1110; 29.19%) (P = 0.29;
OR = 0.90, 95% CI = 0.75–1.09)] (Fig. 1).
The rate of OHSS was also not statistically different
between FSH-only protocols and LH-containing proto-
cols [recFSH (34/1888; 1.80%) vs. FSH/LH (29/1843;
1.57%) (P = 0.79; OR = 1.08, 95% CI = 0.63–1.83)]
(Fig. 2).
Eighteen trials assessed the ongoing pregnancy rate,
which showed no significant difference between both
groups [(recFSH (544/2385; 22.81%) vs. FSH/LH (589/
2363; 24.93%) (P = 0.31; OR = 0.93, 95% CI =
0.81–1.07)] (Fig. 3).
The clinical pregnancy rate (CPR) significantly favored
additional LH activity [(recFSH (748/2758; 27.1%) vs.
FSH/LH (838/2772; 30.2%) (P = 0.008; OR = 0.85, 95%
CI = 0.76–0.96)], whereas the number of oocytes was
higher with FSH-only protocols (recFSH vs. FSH/LH,
Figure 1
Live birth rate.
Figure 2
Ovarian hyperstimulation rate.
Questioning the value of LH activity Al-Inany et al. 115
P = 0.002; MD = 1.25; 95% CI = 0.48–2.02). Subgroup
analysis of CPR showed a significant difference in favor of
hMG, but not recFSH + recLH. Therefore, LH activity
per se could not be the underlying mechanism accounting
for this significant difference (Figs 4 and 5).
DiscussionLH is a glycoprotein that plays a crucial role in
folliculogenesis during the natural ovarian cycles. It
exerts its activity in theca cells, inducing androgen
production, the substrate of estradiol, as well as in
granulosa cells, where it regulates, together with FSH,
the local production of various molecules (inhibin B and
growth factors) that are important in promoting follicular
maturation [7].
Despite this clear physiological role of LH in folliculo-
genesis, the role of exogenous LH activity in ovarian
stimulation has been the subject of intense debate [8,9].
Premature luteinization and spontaneous ovulation re-
sulting from premature LH surges presented significant
challenges to early ovarian stimulation protocols until the
introduction of GnRHa, which significantly reduced the
incidence of LH surges and increased the pregnancy rates
by overcoming this unwanted phenomenon [10].
That early, researchers did not pay much attention to the
low levels of LH resulting from this desensitization, as at
that time, ovarian stimulation was carried out using
gonadotrophins with LH activity. Nonetheless, with the
introduction of gonadotrophins devoid of LH activity in
the 1990s [11–13], the interest in the role of LH during
ovarian stimulation started to grow.
The perplexity created by the contradictory data on the
essential physiological role of LH and its debatable
therapeutic role has further motivated researchers to
assess the importance of LH activity during follicular
development and its potential value during ovarian
stimulation for IVF by comparing FSH-only protocols
with LH-containing protocols in RCTs.
For FSH-only protocols, recFSH is the purest form of
FSH that contains no LH activity, whereas LH activity
can be provided as hMG (from urinary source) or as
recombinant LH (recLH).
Comparing recFSH versus hMG (urinary source LH)
Earliest meta-analysis that compared recFSH and hMG
treatment in normogonadotrophic patients undergoing a
GnRHa long protocol was carried out by Van Wely et al. [14]
that included four RCTs. The authors failed to show any
statistically significant difference in the main outcome
measures (ongoing pregnancy rates and live birth rate).
As more RCTs addressing the same question were carried
out, systematic reviews and meta-analyses were subse-
quently published summarizing the extracted data [3,4].
The study carried out by Coomarasamy et al. [3] included
seven RCTs [15–20](European and Israeli Study Group
on highly purified menotropin vs. recombinant FSH,
2002) with a total of 2159 patients. In that meta-analysis,
live birth rates were significantly increased by 4% in
patients treated with hMG compared with those treated
with recFSH (95% CI: 0.4–7.5).
A subsequent systematic review and meta-analysis by
Al-Inany and colleagues included two more studies [21,22]
Figure 3
Ongoing pregnancy rate.
116 Evidence Based Women’s Health Journal
and a further 689 patients and confirmed the above
finding [4] as live birth rates were found to be significantly
increased by 3.4% (95% CI: 0.3–6.5) in women randomized
to receive hMG compared with those randomized to receive
recFSH after downregulation with a long GnRHa protocol.
The evaluation of the secondary outcome measures
including the occurrence of OHSS and of multiple
pregnancies did not show significant differences in both
meta-analyses [3,4]. However, in the meta-analysis by Al-
Inany and colleagues, the duration of ovarian stimulation
was significantly shorter in women receiving hMG
compared with those who received recFSH (weighted
MD: – 1.21 days, 95% CI: – 1.35 to – 1.06) after
downregulation with a long GnRHa protocol.
Whether the GnRH antagonist protocol could yield similar
or different results compared with the GnRH agonist long
protocol was addressed in an RCT by Bosch et al. [23], who
evaluated the IVF outcome in 280 patients stimulated with
hMG (n = 140) vs. recFSH (n = 140). In this study, the
number of oocytes retrieved was significantly reduced in
patients treated with hMG compared with those treated
with recFSH [(mean ± SD) 11.3 ± 6.0 vs. 14.4 ± 8.1,
respectively; difference: – 3.1 cumulus–oocyte complexes,
95% CI: – 4.9 to – 1.3]. However, the delivery rates were
not significantly different between patients randomized
to receive hMG vs. those randomized to receive recFSH
(34.3 vs. 31.4%, respectively; risk difference: + 2.9, 95%
CI: –8.1 to + 13.7) [23].
recFSH versus recFSH + recLH
Several researchers have investigated the impact of recLH
addition during ovarian stimulation on the outcome of
IVF/ICSI. A recent meta-analysis has summarized the data
Figure 4
Clinical pregnancy rate.
Questioning the value of LH activity Al-Inany et al. 117
extracted from seven RCTs [24–31] including a total of 701
patients to determine whether the addition of recLH
increases the live birth rate in IVF patients treated with
FSH and GnRHa [32]. No statistically significant differ-
ences in the live birth rates were observed between
patients who received recLH and those who did not when
the seven eligible RCT were pooled (95% CI: – 7.7 to
+ 4.85, P = 0.65; heterogeneity P = 0.32, fixed-effects
model). The result did not change in all subgroup analyses
carried out on the basis of the type of GnRH analogue used
for LH surge inhibition, the time or dose of recLH
addition, or patient’s age.
Consistent with the above findings, the results of a large
RCT carried out by Nyboeandersen and colleagues in
which 526 women were randomized to be stimulated with
either recFSH alone (n = 261) or recFSH with the
addition of recLH (n = 265) from day 6 of stimulation
onwards showed that the ongoing pregnancy rates at
week 10–12 were not significantly different between the
groups (28.7 vs. 27.2%, respectively; RD: + 1.5%, 95%
CI: – 6.1 to + 9.2).
recFSH versus LH-containing protocols (either hMG or
recFSH + rec LH)
In our current meta-analysis, we aimed to evaluate the role
of exogenous LH in ovarian stimulation irrespective of its
source, that is, whether extracted from urine (in the form
of hMG) or manufactured by recombinant DNA technology
(recLH), and also irrespective of the mode of desensitiza-
tion, that is, whether achieved by the long GnRHa protocol
or by the rapidly acting GnRH antagonist protocol.
The results of this systematic review and meta-analysis
failed to show any significant difference in the major
outcome measures (live birth rate and OHSS) when
comparing COH using FSH-only protocols with LH-
containing protocols, suggesting that LH is not of
paramount importance in ovarian stimulation. Moreover,
LH-containing protocols showed a detrimental effect on
the number of oocytes retrieved, which was higher with
FSH-only protocols than with LH-containing protocols.
Although in the current review the CPR favored
additional LH activity significantly, this can be ques-
tioned because the subgroup analysis of CPRs showed a
significant difference in favor of hMG, but not in favor of
recFSH + recLH. Therefore, LH activity per se may not
be the underlying mechanism accounting for this
significant difference.
In this respect, it is worth noting that hMG differs
fromrecFSH not only in the LH activity content but also in
the nature of the FSH contained. Indeed, the human-
derived FSH contained in hMG carries a moreextensive
glycosylation and is closer in its isoformdistribution to the
pituitary FSH. In contrast, recFSH carries a rodent-type
glycosylation that is simpler in structure and that includes a
lower number of sialic acid residues. The glycosylation and
sialilation status of FSH affects its half-life [33] and a
variety of FSH biological properties [34]. It is therefore
possible that some of the differences found between hMG
and recFSH are actually because of the different nature of
the FSH component. Our findings that demonstrated
better pregnancy rates in hMG protocols and not in
recFSH + recLH protocols further endorse this interpreta-
tion. Accordingly, possible differences in the FSH compo-
nent should be taken into due account in future works
investigating the value of the LH supplementation.
FSH isoforms: a new theory for the endocrine aspect
of follicular and oocyte growth
The clinical efficacy of commercially available gonadotro-
phin preparations has been the subject of an intense debate
primarily focused on the origin of FSH activity (urine vs.
recombinant derived) and whether the preparation in-
cluded LH like activity. FSH isoform composition has
received little or no attention, and is usually considered to
Figure 5
Number of oocytes retrieved.
118 Evidence Based Women’s Health Journal
have a negligible effect on clinical effectiveness. However,
in a study carried out by Andersen et al. [35], it was
reported that the FSH isoform profile of commercial
gonadotrophin preparations is of clinical importance and
should be taken into account when evaluating endocrine
aspects and efficacy for each preparation.
FSH exists as a family of isohormones with distinct
oligosaccharide structures, and the FSH isoform mixtures
released change during the follicular phase of the
menstrual cycle. The different isoforms exert a number
of different and divergent biological effects. Exposure of
cumulus–oocyte complexes to less-acidic FSH isoforms in
a pulse-like manner results in a rapid pattern of cAMP
accumulation exceeding that seen with acidic isoforms.
It appears that pulsatile and intermittent release of less-
acidic/short-living FSH isoforms is sufficient to induce
biological responses while allowing the granulosa cell
FSH receptors to regain responsiveness to further FSH
stimulation. This may explain the elevation of progester-
one in recombinant forms (less-acidic isoforms) as these
isoforms are more potent than their counterparts of
urinary origin. Future studies should evaluate the
difference in the premature increase in progesterone in
recFSH and urinary FSH cycles [36].
We can firmly conclude from the current available
evidence at hand that the addition of LH activity to
FSH in ovarian stimulation irrespective of its source, that
is, whether urinary or recombinant, and irrespective of
the pituitary desensitization protocol, that is, whether a
GnRHa long protocol or a GnRH antagonist, did not show
any superiority over FSH-only protocols in terms of the
live birth rate, OHSS rate, and ongoing pregnancy rates.
However, additional LH activity provided as hMG
showed higher CPRs, although it did not when provided
as recLH, indicating that factors other than LH activity
per se may be responsible for this significant difference.
FSH-only protocols yielded more number of retrieved
oocytes than LH-containing protocols.
AcknowledgementsConflicts of interestThere are no conflicts of interest.
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120 Evidence Based Women’s Health Journal
A comparative study between cabergoline, coasting, and
step-down regimens in the prevention of severe OHSS
and their correlation with pregnancy rate in intracytoplasmic
sperm injection cyclesHoda Abdelaal, Olfat N. Riade and Mostafa Mahmoud
Department of Obstetrics & Gynecology, Faculty ofMedicine, Cairo University, Cairo, Egypt
Correspondence to Hoda Abdelaal, Department ofObstetrics and Gynecology, Faculty of Medicine,Cairo University, Cairo, EgyptTel: +01 222 848 993;e-mail: [email protected]
Received 20 November 2011Accepted 16 January 2012
Evidence Based Women’s Health Journal
2012, 2:121–125
Objective
To compare coasting, cabergoline, and step-down methods in the prevention of severe
ovarian hyperstimulation syndrome (OHSS) and their effects on various outcome
measures in intracytoplasmic sperm injection cycles.
Materials and methods
Patients at risk of developing OHSS were randomized into three groups: group A,
which included 16 patients who had undergone coasting by withholding human
menopausal gonadotropin while continuing the gonadotropin-releasing hormone
analogue till the E2 decreased below 3000 pg/ml before triggering, group B
(cabergoline group), which included 28 patients who received 0.5 mg/day for
8 days starting from the day of human chorionic gonadotropin, and group C
(step-down group), which included 30 patients who had decreased the dose of
human menopausal gonadotropin by 1 ampoule to decrease E2 below 3000 pg/ml
then triggering by 10 000 IU of human chorionic gonadotropin and oocytes retrieved
after 34–36 h later.
Results
The number of oocytes retrieved, M2, and number of fertilized oocytes were higher in
the cabergoline group than the other two groups (Po0.05), but the clinical pregnancy
rate was higher in the coasting group (50%) compared with the other two groups and
the lowest in the cabergoline group (14.3%), with no statistical significance between
the three groups in the development of severe OHSS (P = 0.41).
Conclusion
Coasting may have a higher pregnancy rate and may represent a higher preventive
method for the development of severe OHSS than the other two methods.
Keywords:
cabergoline, coasting, intracytoplasmic sperm injection, ovarian hyperstimulation
syndrome, step-down
Evid Based Women Health J 2:121–125& 2012 Evidence Based Women’s Health Journal2090-7265
IntroductionOvarian hyperstimulation syndrome (OHSS) is an iatro-
genic complication of ovarian stimulation for assisted
reproduction technology and other infertility treatments;
usually, it develops several days after oocytes are retrieved
or after assisted ovulation. This syndrome is characterized
by ovarian enlargement because of multiple ovarian cysts
and acute fluid shift into the extravascular space including
ascites, hemoconcentration, hypovolemia, and electrolyte
imbalance [1].
Grades of OHSS are mild, including grade I, II, moderate
grade III, and severe OHSS grade IV, V [2]. Its patho-
genesis is related to increased vascular permeability in the
region surrounding the ovaries and their vasculature [3].
b-Human chorionic gonadotropin (HCG) and its analogs
have been implicated in the past. Vasoactive substances
such as interleukins, tumor necrosis factor-a endothelial,
and vascular endothelial growth factor (VEGF) secreted by
the ovaries have been implicated in the increase in vascular
permeability [4].
VEGF not only stimulates new blood vessel development
in the ovary but also induces vascular hyper permeability
by interacting with the VEGF receptor [5]. The rates of
OHSS are as follows: mild, 8–23%, moderate, 1–7%, and
severe, 0.25–5% [6]. Once the syndrome occurs, little can
be done to alter the course of events and only supportive
measures can be carried out; however, a definite and
useful method is cycle cancelation or no HCG adminis-
tration. Many other methods have been used to prevent
the syndrome. The appropriate protocol and gonadotro-
pin needs to be chosen [7]. Unilateral ovarian follicular
aspiration before the administration of HCG was
successful in some investigations [8]. In another study,
aspiration of half of the follicles before the administration
of HCG reduced the risk of severe OHSS [9].
Original article 121
2090-7265 & 2012 Evidence Based Women’s Health Journal DOI: 10.1097/01.EBX.0000419242.56497.0c
Another method for the prevention of OHSS is the
coasting approach withholding gonadotropin administra-
tion, which has been used in ovulation induction cycles to
prevent excessive response [10]. Recently, a dopamine-
agonist, cabergoline, has been used successfully for the
prevention of severe OHSS (anti-VEGF) [11]. The step-
down human menopausal gonadotropin (HMG) protocol
seems rational as it mimics the natural ovarian cycles
when ultrasound monitoring (usually by stimulation day
7) reveals the advancement of a reasonable number of
developing follicles [12]. The impact of this kind of
management of patients with risk factors is that earlier
close monitoring of serum E2 and ultrasound could be
valuable in determining early evolution of OHSS [13].
Approach might be viewed as further development of
conventional ‘coasting’, yet avoiding the risk of abrupt E2
fall with reduction of oocyte retrieval rate and embryo
quality [14].
The aim of this study was to determine the effect of
cabergoline on the cycle outcome and prevent severe OHSS
and to compare it with other popular methods such as
the coasting method and the step-down method (decreasing
the dose of HMG) in preventing severe OHSS and in the
detection of the cycle outcome and pregnancy rate.
Patient and methodsThe study was approved by the ethical committee of
research in Kasr El-Aini Hospital, Cairo University. This
was a prospective cohort study of couples who were
subjected to intracytoplasmic sperm injection cycles in
the in-vitro fertilization (IVF) unit in Kasr El-Aini
Hospital, Cairo University. Seventy-four women at risk
of developing OHSS were included in the study. This
included young women below 35 years of age, PCO
patients, those with E2 more than 4000 pg/ml during the
follow-up of induction, women with a necklace sign
(antral follicle count 420) before induction, and women
with preovulatory follicular number more than 20 follicles
on both sides or a large number of follicles more than
15 mm during the course of induction.
All women were undergoing the long protocol for
stimulation of cycle. They were downregulated with a
gonadotropin-releasing hormone analogue (GnRH-a)
subcutaneously (Decapeptyl 0.1 mg daily from day 20 in
the previous cycle of stimulation). Then, daily adminis-
tration of HMG was carried out intramuscularly along
with the (GnRH-a). E2 was administered for women at
risk for OHSS to determine the level and counsel the
patient to complete the cycle or not. Women who were at
risk of developing OHSS and did not want to cancel their
cycle were divided into three groups.
Group A, the coasting group, included 16 women, for
whom we continued the GnRH-a, but withheld the
gonadotropins until serum E2 started to decrease, with
the mean duration of coasting being 2–3 days. Then HCG
was administered to this group of women when E2 was
below 3000 pg/ml. Group B, the cabergoline group,
included 28 women who received 0.5 mg/day for 8 days
starting from the day of HCG administration. Group C,
the step-down group, included 30 women in whom the
dose of gonadotropins was decreased by 1 ampoule until
the E2 started to decrease. In all three groups, when at
least three follicles of at least 18 mm in size were
achieved, the HCG dose (10 000 IU) was administered
for triggering.
After the administration of HCG, all three groups were
followed up every 48 h for the detection of severe OHSS;
Hb, hematocrit value, and kidney functions were
determined by follow-up ultrasound for all patients.
The embryo transfer procedure was carried out for all
women using the same method and luteal support was
carried out for all women using progesterone in oil
(800 mg into two divided doses) for 14 days. Clinical
pregnancy was detected by the presence of a gestational
sac or cardiac pulsation 3 weeks after ET.
Data were statistically described in terms of the mean
(SD), median and range, or frequencies (number of
cases) and percentages when appropriate. Comparison of
numerical variables between the study groups was carried
out using the Kruskal–Wallis test, with the Mann–
Whitney U-test for independent samples carried out for
post-hoc multiple two-group comparisons. For comparison
of categorical data, the w2-test was carried out. The exact
test was used when the expected frequency was less than
5. P-values less than 0.05 were considered statistically
significant. All statistical calculations were carried out
using computer programs statistical package for the social
science (SPSS Inc., Chicago, Illinois, USA) version 15 for
Microsoft Windows.
ResultsThe study was carried out between March 2010 and August
2011; we studied 74 patients at the IVF center in Kasr El-
Aini Hospital, Cairo University. The patients were divided
into three groups: 28 patients in the cabergoline group, 30
patients in the step-down group, and 16 patients in the
coasting group, and were evaluated. The mean age of the
patients was 27.4 ± 6.0 years in the coasting group,
29.4 ± 3.7 years in the cabergoline group, and 30.1 ± 5.1
years in the step-down group (P = 0.122).
The mean duration of infertility was 5.41 ± 3.7 years in
the coasting group, 6.0 ± 4.18 years in the cabergoline
group, and 5.2 ± 5.05 years in the step-down group
(P = 0.762). The mean BMI was 27.9 ± 3.1 in the
coasting group, 32.6 ± 6.0 in the cabergoline group, and
in 32.8 ± 3.7 the step-down group (P = 0.001).
Antral follicle count was 17.88 ± 2.14 in the coasting
group, 17.84 ± 2.34 in the cabergoline group, and
18.2 ± 2.18 in the step-down group (P = 0.806). The
number of eight-cell embryos was 1.06 ± 2.331 in the
coasting group, 1.07 ± 1.783 in the cabergoline group, and
2.05 ± 3.349 (P = 0.005) in the step-down group. The
mean number of retrieved oocytes was 14.41 + 5.173 in
the coasting group and 21.50 ± 8.307 in the cabergoline
122 Evidence Based Women’s Health Journal
group (the P-value between these two groups was 0.003),
with a statistically significant difference. The mean
number of retrieved oocytes in the step-down group was
15.73 ± 6.264 (P-value between the step-down and the
coasting group was 0.563), with no statistical significance.
The P-value between the cabergoline and the step-down
group was 0.002, with the overall P-value equal to 0.001.
The mean number of MII was 7.50 ± 2.129 in the coast-
ing group and 13.86 ± 5.536 in the cabergoline group,
with a statistical significance between the coasting and
the cabergoline group (P = 0.001), and the mean number
of MII in the step-down group was 11.27 ± 4.763, with no
statistical significance between the coasting and the step-
down group (P = 0.005), and also no statistical signifi-
cance between the cabergoline and the step-down group
(P = 0.130); the overall P-value is equal to 0.001.
The mean number of fertilized oocytes was 5.65 ± 2.936 in
the coasting group and 5.00 ± 4.225 in the cabergoline
group (P = 0.001). The mean number of fertilized oocytes
was 9.47 + 5.355 in the step-down group (P = 0.007
between the coasting and the step-down group,
P = 0.4115 between the cabergoline and the step-down
group, and overall P = 0.002). The chemical pregnancy rate
was eight women (50%) in the coasting group, four women
(14.3%) in the cabergoline group, and 10 women (33.3%) in
the step-down group; the overall P-value was 0.038.
The number of women who developed severe OHSS was
zero in the coasting group, two women in the cabergoline
group, and one woman in the step-down group; the
overall P-value was 0.481. The mean E2 on the day of
HCG was 4512 ± 752 in the coasting group, 4396 ± 1906
in the cabergoline group, with no statistical significance
between them (P-value = 0.687), and 4120 ± 2978 in the
step-down group, with no statistical significance between
the coasting and the step-down groups (P = 0.064) and
also no statistical significance between the cabergoline
and the step-down groups (P = 0.171); the overall P-value
was 0.156 (Table 1).
DiscussionOne of the major, dangerous complications of ovarian
stimulation in IVF-intracytoplasmic sperm injection women
is OHSS, which may be life threatening. There are some
measures for the prevention of OHSS; the most effective
method of prevention is cancelation of the cycle, but in
most of the IVF centers, the couple refuses the cancelation
because of financial and emotional causes. Another method
for the prevention of OHSS is freezing all embryos and
postponing embryo transfer to the subsequent cycle [15];
also, another approach for the prevention of OHSS is
follicular aspiration before the administration of HCG [8].
There are other methods for reducing the risk for severe
OHSS; one of these methods is coasting, which is
withholding the administration of gonadotropin and post-
poning the HCG injection while continuing the GnRH
agonist till the E2 level increases to less than 3000 pg/ml.
Coasting causes atresia of a large number of small follicles,
and thus leads to a decrease in the serum E2 level and
vasoactive mediators [16]. A decrease in the serum level of
FSH concentrations downregulates the LH receptors of
the follicles; thus, this results in the maturation of a fewer
number of oocytes by HCG and leads to a reduction in the
number of oocytes retrieved [16].
In our study, we used cabergoline for the prevention of
severe OHSS, which has been used successfully in high-
risk patients for OHSS. Cabergoline inactivates the
VEGFR-2; this growth factor is very important in
endometrial angiogenesis during the beginning of the
secretory phase [17]. Moreover, VEGF expression is
important in the growth and development of the
endometrium with advancing stages of the menstrual
cycle. VEGF expression has been especially correlated
with implantation of the embryo [17]. It has been shown
that pharmacological doses of cabergoline can inhibit
VEGF-mediated microvascular permeability, proliferation,
and migration of endothelial cells in vitro by inducing
endocytosis of VEGF-R2 [17]. Another study has shown
that changes in VEGF-R2 induced by low-dose cabergo-
line reversed the occurrence of increased vascular
permeability without altering angiogenesis [18]. Cabergo-
line used for the prevention of OHSS reduced neither the
rate of pregnancy nor the implantation rate [18].
In our study, we found that the number of retrieved
oocytes in the cabergoline group was higher than that of
the coasting group (P = 0.003); also, the number of MII
and number of fertilized oocytes in the cabergoline group
Table 1 Patient demographic data
Coasting Cabergoline Step-down P-value
Age 27.4 ± 6 29.4 ± 3.7 30.1 ± 5.1 0.122Duration of infertility 5.41 ± 3.7 6 ± 4.18 5.2 ± 5.05 0.762BMI 27.9 ± 3.1 32.6 ± 6.0 32.8 ± 3.27 0.001AFC 17.88 ± 2.14 17.84 ± 2.34 18.2 ± 2.18 0.806E2 of day HCG 4512 ± 752 4396 ± 1906 4120 ± 2978 0.156Outcome measures
Number of retrieved oocytes 14.41 ± 5.17 21.5 ± 8.307 15.73 ± 6.26 0.001Number of MII 7.5 ± 2.129 13.86 ± 5.536 11.27 ± 4.763 0.001Number of fertilized oocytes 5.56 ± 2.93 10.07 ± 4.22 9.47 ± 5.355 0.002Number of eight-cell embryos 1.06 ± 2.33 1.07 ± 1.78 3.53 ± 4.34 0.005Chemical pregnancy rate 8 (50%) 4 (14.3%) 10 (33.3%) 0.038Rate of OHSS 0 2 1 0.481
AFC, antral follicle count; HCG, human chorionic gonadotropin; OHSS, ovarian hyperstimulation syndrome.
Cabergoline for the prevention of severe OHSS Abdelaal et al. 123
were higher than those of the coasting group (P = 0.001
and 0.002, respectively). The eight-cell embryos in the
coasting group (1.06 ± 2.331) were less than those in the
cabergoline group (1.07 ± 1.783) (P = 0.511).
Also, the chemical pregnancy rate in the coasting group
(50%) was higher than that of the cabergoline group
(14.3%) (P = 0.016); although the number of oocytes
retrieved was affected by coasting, the endometrial
receptivity was affected in the cabergoline group and
thus the clinical pregnancy rate was lower in the
cabergoline group.
These results are in agreement with those of Aflatoonian
et al. [19], as they found that the number of retrieved
oocytes, number of MII, eight-cell embryos, and the
number of patients who developed severe OHSS is higher
in the cabergoline group than in the coasting group.
However, our results differ from theirs in terms of the
pregnancy rate as they found that the pregnancy rate in
the cabergoline group was higher than that of the coasting
group.
In terms of the development of severe OHSS in the
coasting group, no cases were reported, but in the
cabergoline group, two women developed severe OHSS,
with no statistical significance between them (P = 0.48).
The third method we used in this study was the step-
down of the HMG by 1 ampoule in suspicious cases for
OHSS and follow-up by E2 every other day to reach less
than 3000 pg/ml to yield HCG. The step-down in
induction of ovulation will allow more follicles to undergo
atresia, thus reducing the overall number of follicles
capable of secretory activity by the time of HCG
administration; thus, this leads to a reduction in the rate
of OHSS [20]. On comparison of the coasting and the
step-down group, we found that the number of retrieved
oocytes in the step-down group was higher than that of
the coasting group, but with no statistical significance
between them (P = 0.563), and the number of MII in the
step-down group was higher than that of the coasting
group (P = 0.005) (positive statistical significance). Also,
the number of fertilized oocytes in the step-down group
was higher than that of the coasting group, with no
statistical significance (P = 0.007). The number of eight-
cell embryos in the step-down group was higher than that
of the coasting group, with no statistical significance
(P = 0.009).
Also, in terms of the eight-cell embryo number in each
group, there was a significant difference among the three
groups, with an overall P-value equal to 0.005.
The chemical pregnancy rate in the step-down group was
33.3% (10 cases), which is lower than the chemical
pregnancy rate in the coasting group of 50% (eight cases)
(P = 0.270). In the step-down group, only one woman
developed severe OHSS, but in coasting group, none of
the women developed severe OHSS, with no statistical
significance between them.
When we compared the results of the step-down group
and the cabergoline group, it was found that the number
of retrieved oocytes in the step-down group was lower
than that of the cabergoline group (P = 0.002), but with
no statistical significance between both groups. The
number of MII and number of fertilized oocytes
(P = 0.130 and 0.415, respectively) in the step-down
group were lower than those of the cabergoline group.
The chemical pregnancy rate was 33.3% (10 cases) in the
step-down group and 14.3% (four cases) in the cabergo-
line group (P = 0.090). There was no statistical signifi-
cance in the occurrence of severe OHSS among both
groups.
ConclusionWe found that the number of retrieved oocytes, MII, and
fertilized oocytes were higher in the cabergoline group
than the other two groups, but the chemical pregnancy
rate in the coasting group was higher than that of
the other two groups, and the cabergoline group had the
lowest pregnancy rate, with no difference in the
development of severe OHSS.
AcknowledgementsConflicts of interestThere are no conflicts of interest.
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Cabergoline for the prevention of severe OHSS Abdelaal et al. 125
Antral follicular count is a better indicator for the assessment of
ovarian reserveAhmed Solimana, Sherif Sharkawya, Tamer Abdelmoniemb, Hesham Al-Inanya
and Odette Wahbac
aDepartment of Obstetrics and Gynecology, CairoUniversity, bDepartment of Obstetrics and Gynecology,Al-Salama Hospital, Kuwait and cGenomic MedicineUnit, Cairo University, Cairo, Egypt
Correspondence to Ahmed Soliman, MD, Departmentof Obstetrics and Gynecology, Faculty of Medicine,Cairo University, Cairo, EgyptTel: + 01 009 811 128;e-mail: [email protected]
Received 3 May 2012Accepted 28 June 2012
Evidence Based Women’s Health Journal
2012, 2:126–132
Objectives
To assess the ovarian reserve using the antral follicular count (AFC) versus the basal
serum anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), E2, and
serum progesterone according to the ovarian response and the chemical pregnancy
rate.
Material and methods
Eighty-six women undergoing Intra Cytoplasmic Sperm Injection or IVF for male factor,
tubal factor, or unexplained infertility were studied using a long luteal phase protocol
for induction of ovulation. All patients were subjected to measurements of basal serum
FSH, E2, progesterone, and AMH and also assessment of AFC. The ovarian response
was determined by the number of oocytes retrieved. The correlation between different
tests and outcomes was determined.
Results
There was a significant statistical difference between the good and the poor
responders in terms of the basal serum FSH level, serum AMH, and AFC (6.45 ± 2.27
and 12.95 ± 6.69 IU/ml), (0.692 ± 0.819 and 0.227 ± 0.505 ng/ml), and (11.76 ± 5.3
and 5.71 ± 3.3 follicles), respectively. Receiver-operator characteristic curve showed
that both FSH and AMH have limited value in predicting the ovarian response, with
a sensitivity and specificity of 9.26 IU/ml, 70 and 91.2%, likelihood ratio 7.927, and
0.11 ng/ml, 73.33 and 72.85%, likelihood ratio 2.7, respectively, but the AFC has
a high value in predicting the ovarian response; the cut-off value, sensitivity, and
specificity were 8, 85.71 and 73.46%, likelihood ratio 3.22. All the investigated tests
showed limited value in predicting pregnancy.
Conclusion
All three basal serum FSH, AMH, and AFC seem to predict the ovarian reserve but the
AFC is superior to FSH and AMH, and it is less invasive and cheaper.
Keywords:
Anti-Mullerian hormone, ICSI, infertility, IVF, ovarian reserve, ovarian response
Evid Based Women Health J 2:126–132& 2012 Evidence Based Women’s Health Journal2090-7265
IntroductionOvarian reserve (OR), a term that has evolved in the era
of assisted reproductive technology (ART), refers to the
residual oocyte–granulosa cell repertoire that, at any
given age, is available for procreation. Both quantitative
and qualitative deteriorations in the oocyte complement,
and therefore a waning OR, are recognized phenomena
associated with advancing age. Although a decline in OR
thus accompanies chronological aging, there is an
acceleration in this process [1].
Diminished OR is defined as a decrease in the
reproductive potential of a woman’s remaining oocytes
to the point at which the probability of producing a viable
gestation is low. The age-related decline in reproductive
potential is the principal factor contributing toward the
increase in the prevalence of infertility in western
society [2]. A cut-off level of less than six antral follicles
used by Kwee et al. [3] had a sensitivity of 41% and
a specificity of 95%, with a prevalence of 27% for a poor
response. In the population studied after ovarian
hyperstimulation in an IVF treatment, the accuracy was
89% [3].
OR tests can identify the high-risk population of poor
response, and hence yield information that affects
prognosis, counseling, and treatment decisions. Abnormal
tests in older women can help to persuade patients to
abandon plans to pursue aggressive and costly treatment.
On the other hand, mild abnormal test in young women
can help to convince them to do just the opposite and to
take the fullest advantage of a rapidly closing window of
opportunity [4].
Over the past two decades, a number of so-called ovarian
reserve tests (ORTs) have been designed to determine
oocyte reserve and quality and have been evaluated for
their ability to predict the outcome of IVF in terms of
oocyte yield and the occurrence of pregnancy. Many of
126 Original article
2090-7265 & 2012 Evidence Based Women’s Health Journal DOI: 10.1097/01.EBX.0000419240.48874.b7
these tests have become part of the routine diagnostic
procedure for infertility patients who undergo assisted
reproductive techniques. The unifying goals are tradi-
tionally to determine how a patient will respond to
stimulation and their chances of pregnancy [5].
Several tests have been proposed to define the OR status
of individual patients and predict fertility outcomes for
assisted reproduction and these include age, history of
canceled cycles, clinical symptoms (e.g. oligomenorrhea),
basal blood tests [follicle-stimulating hormone (FSH),
luteinizing hormone (LH), anti-Mullerian hormone
(AMH), estradiol (E2), FSH/LH ratio, inhibin B, proges-
terone (P4), P4 : E2 ratio, testosterone, vascular endothelial
growth factor (VEGF), insulin-like growth factor-1 : insulin-
like growth factor binding protein-1 ratios (IGF-1 : IGFBP-1
ratio)]. Dynamic tests (clomiphene citrate challenge test
(GnRH agonist stimulation test, exogenous FSH ovarian
reserve test). Ultrasound tests [ovarian volume, antral
follicle count (AFC), ovarian stromal blood flow] [6,7].
Materials and methodsPatients
This is a prospective cross sectional study carried out at
the IVF center of the Egypt International Hospital
between January 2007 and February 2009, and included
86 patients who would be undergoing IVF or ICSI for the
first time with the following inclusion criteria: age from
31 to 49 years, cause of infertility male factor, tubal factor,
or unexplained infertility, basal FSH level below 15 mIU/ml,
both ovaries well visualized by transvaginal sonography
without any cysts, no criteria of polycystic ovary, no history
of ovarian surgery, no history of endocrinological disorder,
and no history, symptoms, or signs of endometriosis. The
study was discussed with the patient before her participa-
tion and consent was taken.
Study protocol
All patients of the study were recruited on days 2–5 of the
cycle; before the ovulation protocol was carried out, they
were subjected to the following: full history taking and
a thorough clinical examination, transvaginal sonography
for the assessment of the AFC, both ovaries, and the
uterus, and to exclude any pelvic pathology. For ultra-
sonographic evaluation, we used transvaginal 7.5 MHz
(Sonoace 9900; Medison, Seoul, Korea).
Measurements of basal serum FSH, E2, progesterone,
and AMH were carried out. Also, routine laboratory tests
such as complete blood test and assessment of liver and
kidney functions were carried out.
Induction of ovulation was carried out using the long
luteal phase protocol. All patients received Decapeptyl
(GnRHa) 0.1 mg subcutaneous injection daily at 8 p.m.
starting from day 20 of the cycle and for 2 weeks, after
insuring downregulation by serum E2 level; human
menopausal gonadotropins (hMG) injection was adminis-
tered at a starting dose of 150–300 IU/day for 7 days and
then adjusted according to the response. The patient was
monitored every other day for folliculometry. Human
chorionic gonadotropin (hCG) was administered if the
mean follicular diameter was 18–20 mm at a dose of
10 000 IU intramuscular injection; if the mean diameter
of the follicles was less than 10 mm after 14 days, the
cycle was canceled. Ovum pick up wascarried out after
36 h of hCG and embryo transfer was carried out on day 2
or 3. Pregnancy was confirmed by a positive qualitative
B-hCG test 2 weeks after embryo transfer.
Hormone assays
Serum FSH, E2, and AMH were measured on cycle day 3,
whereas progesterone was measured on cycle day 1. Both
E2 and progesterone were measured again on the day of
hCG administration. Serum FSH was measured using
radioimmunoassay (RIA) (Gambyt-CR; Diagnostic Pro-
ducts Corporation, Los Angeles, California, USA). The
interassay coefficient of variation (CV) of FSH was 3.7%.
The intra-assay CV was 4.7%.
Serum AMH was measured using two enzyme-linked
immunosorbent assays. In the traditional assay, Immulon
two plates (Dynatech Corp., Chantilly, Virginia, USA)
were coated with monoclonal antibody 10.6 (Dr R. Cate,
Cambridge, Massachusetts, USA), raised against recom-
binant human AMH by an overnight incubation at room
temperature. Sera were assayed at 1 : 4, 1 : 8, 1 : 16, and
1 : 32 dilutions in PBS containing 1% BSA. As the second
antibody, we used polyclonal antibody L40, consisting of
an immunoglobulin G fraction isolated by affinity
chromatography on protein A-Sepharose from the serum
of a rabbit immunized with recombinant human AMH.
L40 was added to the wells at 1 mg/ml in PBS–1% BSA for
1 h at room temperature. Subsequently, an alkaline
phosphatase-labeled goat anti-rabbit immunoglobulin G
antibody (Jackson ImmunoResearch Laboratories Inc.,
West Grove, Pennsylvania, USA) was added and incu-
bated for a further hour before the reaction was visualized
with an MRX spectrophotometer (Dynatech Corp.) at
405 nm, using paranitrophenyl phosphate (Sigma Chimie,
Saint-Quentin-Fallavier, France) as a substrate.
Estradiol levels were measured by RIA. Duplicate
aliquots (0.2 ml) of plasma were fixed with 0.1 ml of a
1.5 mol/l sodium carbonate solution, pH 10.5, and
extracted with 10 vol of diethyl ether. The mixture was
frozen, the ether was decanted and evaporated, and the
residue was dissolved in PBS and incubated with tritium-
labeled E2 (Amersham International, Little Chalfont,
Buckinghamshire, UK) and sheep anti-E2 antiserum
(Bioclin Services, Cardiff, Wales, UK). Bound and free
E2 were separated using dextran-coated charcoal. The
interassay CVs for two control plasmas were 9.5 and 6.6%
for E2 concentrations of 174 and 409 pmol/l, respectively.
Serum progesterone was measured using RIA (Gambyt-
CR; Diagnostic Products Corporation). The intra-assay
and interassay CV were 9.6 and 4.9%.
Outcome measures
The main outcome of the study was the ovarian response
and was determined according to the number of oocytes
retrieved; five or more was considered to indicate a good
response and less than five was considered a poor
AFC as indicator for ovarian reserve Soliman et al. 127
response. The secondary outcome was the chemical
pregnancy rate (PR).
Statistical analysis
Data were statistically described in terms of range,
mean ± SD, median, frequencies (number of cases),
and relative frequencies (percentages) when appropriate.
Comparison of quantitative variables between different
groups in the present study was carried out using the
Mann–Whitney U-test for independent samples. For
comparison of categorical data, the w2 test was carried
out. Exact test was used when the expected frequency
was less than 5. Accuracy was represented using the terms
sensitivity and specificity. Receiver-operator characteris-
tic (ROC) analysis was used to determine the optimum
cut-off value for the diagnostic markers studied. Correla-
tions between various variables were determined using
Pearson’s moment correlation and Spearman’s rank
correlation equations. A probability value (P value) less
than 0.05 was considered statistically significant. All
statistical calculations were carried out using computer
programs Microsoft Excel version 7 (Microsoft Corpora-
tion, New York, USA), SPSS (Statistical Package for the
Social Science; SPSS Inc., Chicago, Illinois, USA), and
the ArcusQuickStat (Biomedical version; Addison Wesley
Longman Ltd, USA) statistical program.
ResultsAll the 86 patients were eligible for analysis; the patients
were categorized according to the response into good
responders, who retrieved five or more oocytes, or poor
responders, who retrieved less than five, and according to
the result of the B-hCG test as a positive test (chemical
pregnancy) or a negative test. 81.4% (70 patients) were
good responders and 18.6% (16 patients) were poor
responders, and the chemical PR was 33.72% (29
patients).
Table 1 shows a comparison of both groups in terms of the
general variables and it indicates that there was a
statistically significant difference between both groups
in terms of the patient age, duration of infertility, and
number of hMG ampoules used. As the poor responders
were older than the good responders and they had more
long-standing infertility, they required more hMG am-
poules to be stimulated.
In terms of the other variables, when we compared both
groups, it was found that there was a statistically
significant difference in the basal serum FSH level (Pvalue 0.000), serum AMH (P value 0.001), and basal AFC
(P value 0.003), whereas there was no statistically
significant difference between both groups in the basal
levels of E2 and progesterone. Measurement of the E2
and progesterone levels on the day of hCG administration
indicated that there was a statistically significant
difference between both groups in the E2 level, whereas
the progesterone level was insignificant. Table 2 shows
a comparison between both groups in terms of these
variables.
On analyzing the previous data on the ROC curve
characteristic, we found that basal AFC was superior to
basal serum FSH and serum AMH in the prediction of
the ovarian response; the best cut-off value, sensitivity,
specificity, and likelihood ratio for each test are presented
in Table 3.
The secondary outcome was the chemical PR, which was
33.72% (29 patients). Table 4 presents a comparison of
the group with a positive pregnancy test and those with a
negative pregnancy test in terms of the basal serum FSH,
Table 1 Background characteristics of the study population
Variables Total (n = 86) Good responders (n = 70) Poor responders (n = 16) P value
Mean age ± SD 31.41 ± 5.7 29.68 ± 4.391 38.44 ± 4.77 0.0000 (S)Mean BMI 29.65 ± 4.41 28.52 ± 5.5 29.9 ± 4.1 NSDuration of infertility (years) 6.34 ± 4.6 5.43 ± 3.7 10.27 ± 5.7 0.001 (S)Type of infertility
Primary 53 (61.62%) 14 (16.27%)Secondary 17 (19.767%) 2 (2.32%)
Mean number of hMG ampoules used 38.69 ± 14.2 49.56 ± 19.42 0.02 (S)Mean duration of stimulation 11.28 ± 5.65 10.69 ± 2.49 NS
hMG, human menopausal gonadotropin; S, significant.
Table 2 Hormonal assay of follicle-stimulating hormone, Estradiol, progesterone, anti-Mullerian hormone
Variables Total (n = 86) Good responders (N = 70) Poor responders (N = 16) P value
Basal serum FSH ± SD (IU/ml) 8 ± 4.46 6.45 ± 2.27 12.95 ± 6.69 0.000 (S)Basal serum E2 ± SD (pg/ml) 26.1 ± 30.71 26.67 ± 33.26 23.75 ± 16.66 NSSerum E2 level on day of hCG (pg/ml) 22 394.43 ± 1714.92 2580 ± 1689.62 874.2 ± 1025.84 0.000 (S)Value of change in E2 level (pg/ml) 2147.7 ± 1809.9 2347.69 ± 1811.84 987.8 ± 1440 0.03 (S)Basal serum progesterone level (ng/ml) 0.554 ± 0.487 0.587 ± 0.504 0.318 ± 0.268 NSSerum progesterone level on day of hCG (ng/ml) 0.964 ± 0.668 0.927 ± 0.565 1.118 ± 1.02 NSBasal serum AMH (ng/ml) 0.613 ± 0.819 0.692 ± 0.819 0.277 ± 0.505 0.001 (S)Basal AFC 10.94 ± 5.5 11.76 ± 5.3 5.71 ± 3.3 0.003 (S)
AFC, antral follicular count; AMH, anti-Mullerian hormone; FSH, follicle-stimulating hormone; hCG, human chorionic gonadotropin; S, significant.
128 Evidence Based Women’s Health Journal
E2, progesterone, AMH, and AFC. The data showed
that none of these tests showed a statistically significant
difference between both groups, except in the basal
FSH (6.65 ± 2.31 and 9.23 ± 5.23) and the basal AFC
(8 ± 5.3 and 8.77 ± 4.48), respectively. After plotting
the data on the ROC curve, it was found that none
of the tests used had a high power of prediction or
correlation with pregnancy. The data are shown in Table 5
(Figs 1–3).
DiscussionIn this study, we used different tests for the prediction of
the ovarian response in 86 patients undergoing IVF or
ICSI for the first time; we found that age showed a strong
relationship with the response as the mean age for the
good responders and the poor responders was (68 ± 4.391
and 38.44 ± 4.77), respectively. In a study carried out by
Van Voorhis [8], it was concluded that age is a well-
established predictor for the OR. And the good Odds
Ratio can be suggested by age less than 38 years at the
time of treatment, as the decay rate of resting follicles
accelerates from 38 years onwards [9,10].
Also, a relatively longer duration of infertility was
observed in poor responders, 10.27 ± 5.7 years, whereas
in good responders, it was 5.43 ± 3.7 years. This can be
attributed to the fact that patients with a poor OR would
have undergone more trials of ICSI with poor results,
thus increasing the duration of infertility. As reported by
Hammadieh et al. [11], increasing duration of infertility is
associated with a decrease in the probability of sponta-
neous pregnancy in untreated infertile couples (15.3% for
1–3 years, 14% for 4–6 years, 12.9% for 7 – 9 years, 12.4%
for 10–12 years, and 8.6% for more than 12 years).
The number of hMG ampoules used in both good and
poor responders showed a statistically significant differ-
ence (38.69 in good responders and 49.56 in poor
responders), and this can be considered a logical result
in poor responders. A small number of randomized-
controlled trials and retrospective studies have evaluated
the effectiveness of high-dose FSH regimens beyond
Table 4 Pregnancy outcome according to different parameters
Variables Positive pregnancy test (N = 29) Negative pregnancy test (N = 57) P value
Basal serum FSH (IU/ml) 6.65 ± 2.31 9.23 ± 5.23 0.001 (S)Basal serum E2 (pg/ml) 18.94 ± 12.79 34.06 ± 43.86 NSSerum E2 on day hCG injection (pg/ml) 2424.05 ± 2129 1967.19 ± 137794 NSBasal progesterone level (ng/ml) 0.485 ± 0.47 0.613 ± 0.538 NSSerum progesterone level on day hCG injection (ng/ml) 0.913 ± 0.7 0.939 ± 0.636 NSBasal serum AMH (IU/ml) ± SD 0.764 ± 0.86 0.58 ± 0.904 NSBasal AFC ± SD 8 ± 5.3 8.77 ± 4.48 0.002 (S)
AFC, antral follicular count; AMH, anti-Mullerian hormone; FSH, follicle-stimulating hormone; hCG, human chorionic gonadotropin; S, significant.
Table 5 Accuracy of different test in predicting pregnancy
Variables Cut-off value Sensitivity (%) Specificity (%) Likelihood ratio Area under ROC curve (%)
Basal FSH 4.935 IU/ml 33.33 95.45 7.32 64.58o75Basal E2 47.32 pg/ml 100 15.38 1.18 54.35o75Basal AMH 0.3 ng/ml 65.38 63.88 1.81 46.84o75Basal AFC 9.048 91.3 59.1 2.23 70.45o75
AFC, antral follicular count; AMH, anti-Mullerian hormone; FSH, follicle-stimulating hormone; ROC, receiver-operator characteristic.
Table 3 Accuracy of different parameters
Data set Cut-off value Sensitivity (%) Specificity (%) Likelihood ratio Area under ROC curve (%)
Basal serum FSH 9.26 IU/ml 70 91.2 7.927 74.26o75Basal serum AMH 0.11 ng/ml 73.33 72.85 2.7 71.1o75AFC 8.022 85.7 73.469 3.22 85.5475
AFC, antral follicular count; AMH, anti-Mullerian hormone; FSH, follicle-stimulating hormone; ROC, receiver-operator characteristic.
Figure 1
ROC plot for FSH in predicting poor response
0.00 0.25 0.50 0.75 1.000.00
0.25
0.50
0.75
1.00Sensitivity
1-Specificity
9.25832
FSH
Receiver-operator characteristic plot for basal follicle-stimulatinghormone in predicting a poor response.
AFC as indicator for ovarian reserve Soliman et al. 129
a 300 IU threshold. The results of these studies have
shown these approaches to be of little or no clinical
benefit, although both the costs of treatment and the
side-effects were higher. Other studies have examined
regimens of 450 IU FSH or even higher [12]. The
number of days of stimulation by hMG in patients
showed an insignificant statistical difference: 11.28 days
in good responders and 10.69 days in poor responders.
Lengthy, expensive regimens are not free from short-term
and long-term risks and complications.
In our study, the result of ovarian stimulation was
expressed as the number of oocytes retrieved: greater
than or equal to five was considered a good response and
less than five was considered a poor response for both
groups [13]. Seventy patients produced five or more
oocytes (81.4%) whereas 16 patients produced less than
five oocytes (18.6%). However, 29 patients (33.72%)
achieved chemical pregnancy whereas 57 (66.28%) did
not.
The AFC was studied as an ORT. OR may be defined as
the total number of follicles that can be stimulated under
maximal ovarian stimulation with FSH. ORTs are
considered to indirectly reflect the size of the cohort of
small antral follicles (2–10 mm in diameter) in the ovary.
Thus, a decrease in follicle number increases the risk of a
poor response after ovarian hyperstimulation in patients
with IVF at an older age [3,14].
In our study, AFC was obviously lower in poor responders,
5.71, whereas it was 11.76 in good responders, with a
statistically significant difference (P value 0.003) (the
mean AFC in all patients was 10.94). Taking P value less
than 0.05, AFC was considered significant for a poor
response. In ROC curve analysis, area under the curve is
greater than 75% (85.56), that is the value of testing AFC
in predicting a response is high. With an optimum cut-off
point = 8, the highest sensitivity and specificity that
could be obtained were 85.71 and 73.46%, respectively.
The likelihood ratio was 3.22. The mean value of AFC on
cycle day 3 in pregnant patients was 8 ranging from 5 to
30. In nonpregnant patients, the mean value was 8.77,
ranging from 3 to 17. There was a statistically significant
difference (P value 0.002). Area under the curve was less
than 75% (70.45), that is the value of testing AFC in
predicting pregnancy was low. At a cut-off value of 9.048,
the sensitivity was 91.3% and specificity was 59.1%. The
likelihood ratio was 2.23. And this agrees with that more
number of decreases implantation rates [15]. Another
study showed that a low AFC less than 10 antral follicles
with a diameter measuring 2–10 mm was found to
indicate reduced OR and decreased chance for pregnancy
after ART [16].
The mean basal FSH among patients was 8 IU/ml. In good
responders, it was 6.45 ± 2.27 IU/ml, whereas in poor
responders it was 12.95 ± 6.69 IU/ml, with a statistically
significant difference when considering P value less than
0.05 as significant. In ROC curve analysis, area under the
curve was less than 75% (74.26), that is the value of testing
FSH in predicting response is low. With an optimum cut-
off point = 9.26 IU/ml, the highest sensitivity and specifi-
city that could be obtained were 70 and 91.2%, respectively.
The likelihood ratio was 7.927. The mean value of basal
serum FSH in pregnant patients was 6.65 ± 2.31 IU/ml,
ranging from 2.31 to 11.64 IU/ml. In nonpregnant patients,
the mean value was 9.23 ± 5.23 IU/ml, ranging from 5.23 to
15 IU/ml. There was a statistically significant difference
(P value 0.001). In ROC curve analysis, area under the
curve was less than 75% (64.85), that is the value of testing
FSH in predicting pregnancy is low. With an optimum cut-
off point = 4.94 IU/ml, the highest sensitivity and specifi-
city that could be obtained were 33.33 and 95.46%,
respectively. The likelihood ratio was 7.32.
The literature has consistently suggested that FSH
testing is the best marker for assessing OR and for
predicting the response to super ovulation, with a good
correlation with PRs [17,18] and had significant correla-
tions with FSH-hMG administered, total number of
oocytes retrieved, conception rate, and the possibility of
developing ovarian hyperstimulation syndrome [19,20].
A cut-off point of 5.25 mIU/ml for day 3 FSH was
suggested for predicting OR [20].
Figure 2
ROC plot for AFC in predicting poor response
0.00 0.25 0.50 0.75 1.000.00
0.25
0.50
0.75
1.00Sensitivity
1-Specificity
AFC 8.022
Receiver-operator characteristic plot for antral follicle count in theprediction of a poor response.
Figure 3
ROC plot for AMH in predicting poor response
0.00 0.25 0.50 0.75 1.000.00
0.25
0.50
0.75
1.00Sensitivity
1-Specificity
AMH
.1053
Receiver-operator characteristic plot for basal anti-Mullerian hormonelevel in the prediction of a poor response.
130 Evidence Based Women’s Health Journal
However, an elevated FSH value does not necessarily
mean that a woman will be unable to conceive a
pregnancy naturally. There are many examples of patients
with elevated FSH values who were subsequently able to
conceive without treatment. The ORTs are better used as
a predictor of patients who are not likely to benefit from
ART; young women even with elevated FSH may still
have a favorable IVF outcome [8].
The mean value of serum estradiol days 1–3 was 26.1 pg/ml
in all patients, 26.67 pg/ml in good responders, 23.75 pg/ml
in poor responders, with a statistically insignificant
difference. The mean value of basal serum estradiol days
1–3 in pregnant patients was 18.94 pg/ml, ranging from 5 to
47 pg/ml. In nonpregnant patients, the mean value was
34.06 pg/ml, ranging from 10 to 189 pg/ml. There was a
statistically insignificant difference (P value 0.177). In
ROC curve analysis for the ability of basal day 3 serum
estradiol to predict pregnancy, the area under the curve was
less than 75% (54.35), that is the value of testing estradiol
in predicting pregnancy is low. At a cut-off value of
47.32 IU/ml, the sensitivity was 100% and specificity was
15.38%. The likelihood ratio was 1.18.
In a study carried out to test the hypothesis that elevated
E2 levels on day 3 of IVF cycles without a GnRH agonist
are associated with reduced oocyte numbers and PRs, the
ongoing PR per retrieval for patients with E2 levels less
than 30 pg/ml was significantly higher than that for
patients with E2 levels 31–75 pg/ml. There were no
pregnancies if the E2 level was greater than 75 pg/ml.
The mean number of oocytes per retrieval was signifi-
cantly lower in patients from the E2 groups with E2
greater than 60 pg/ml compared with patients in groups
with E2 less than 60 pg/ml. Day 3 FSH and E2 levels were
also evaluated simultaneously. In patients with the lowest
levels of FSH and E2, the PR was the highest. No
pregnancies occurred if the FSH level was greater than
17 mIU/ml (conversion factor to SI unit, 1.00) and the E2
level was greater than 45 pg/ml on day 3 [21].
A systematic analysis of all studies testing basal serum
estradiol as an ORT concluded that the clinical applic-
ability for basal estradiol as a test before starting IVF is
prevented by a very low predictive accuracy, both for poor
response and for nonpregnancy [5].
The mean value of serum estradiol day hCG injection was
2239.43 pg/ml in all patients: 2580 pg/ml in good respon-
ders and 874.2 pg/ml in poor responders, with a significant
statistical difference. The mean value of the basal serum
estradiol day hCG injection in pregnant patients was
2424.05 pg/ml, ranging from 500 to 10 020 pg/ml. In
nonpregnant patients, the mean value was 1967.19 pg/ml,
ranging from 124 to 3806 pg/ml. There was a statistically
insignificant difference (P value 0.497). Serum estradiol on
day of hCG injection reflects the number and health of
oocytes, and showed a statistical difference in predicting
the response however, it couldn’t prove that value.
The mean value of serum progesterone days 1–3 was
0.554 ng/ml in all patients, 0.587 ng/ml in good responders
and 0.318 ng/ml in poor responders, with a statistically
insignificant difference (P value 0.244). The mean value
of serum progesterone day 1–3 in pregnant patients was
0.485 ng/ml, ranging from 0.1 to 2.1 ng/ml. In nonpreg-
nant patients, the mean value was 0.613 ng/ml, ranging
from 0.1 to 1.9 ng/ml. There was a statistically insignif-
icant difference (P value 0.244). The mean value of
serum progesterone day hCG was 0.924 ng/ml in all
patients, 0.927 ng/ml in good responders and 1.118 ng/ml
in poor responders, with a statistically insignificant
difference (P value 0.655). The mean value of serum
progesterone day hCG injection in pregnant patients was
0.913 ng/ml, ranging from 0.3 to 2.9 ng/ml. In nonpreg-
nant patients, the mean value was 0.939 ng/ml, ranging
from 0.3 to 2.5 ng/ml. There was a statistically insignif-
icant difference (P value 0.821).
In a study carried out by Silverberg et al. [22], it was
reported that serum progesterone (P4) levels greater than
0.9 ng/ml on the day of hCG administration were
associated with decreased PRs in IVF/embryo transfer
cycles. Two critical breakpoints were identified: 0.4 and
0.9 ng/ml. Clinical pregnancies occurred in nine of 18
patients in patients with P4 less than 0.4 ng/ml compared
with 11 of 81 patients with P4 between 0.4 and 0.9 ng/ml
(P = 0.001) and zero of 14 patients with P4 more than or
equal to 0.9 ng/ml (P = 0.001). These findings indicate
that even modest increases in serum P4 levels (40.4 ng/ml)
are associated with reduced PRs in IVF/ET cycles. In
addition, it appears that the mechanism may not exclu-
sively involve poor oocyte quality [22].
The mean value of serum AMH day 3 was 0.613 ± 0.819
ng/ml in all patients, 0.692 ± 0.819 ng/ml in good responders
0.277 ± 0.505 ng/ml in poor responders, with a statistically
significant difference (P value 0.001). In ROC curve
analysis, area under the curve was less than 75% (71.71),
that is the value of testing AMH in predicting response was
low. At a cut-off value of 0.11 ng/ml, the sensitivity was
73.33% and the specificity was 72.85% the likelihood ratio
was 2.7. The mean value of basal serum AMH day 3 in
pregnant patients was 0.764 ± 0.86 IU/ml, ranging from 0.05
to 4 IU/ml. In nonpregnant patients, the mean value was
0.58 ± 0.904 IU/ml, ranging from 0.05 to 3.8 IU/ml. There
was a statistically insignificant difference (P value 0.22). In
ROC curve analysis area, under the curve was less than 75%
(46.84), that is the value of testing AMH in predicting
pregnancy was low. At a cut-off value of 0.3 ng/ml, the
sensitivity was 65.38% and specificity was 63.88%. The
likelihood ratio was 1.81. Serum AMH day 3 was useful in
predicting response; however, it was not significant in
predicting pregnancy.
In a study carried out by Gnoth et al. [23] that included
316 patients, a total of 132 oocyte retrievals were
performed. A calculated cut-off level less than 1.26 ng/ml
AMH alone detected poor respondents (o4 oocytes) with a
sensitivity of 97%, and there was a 98% correct prediction
of a normal response in COH if the levels were above this
threshold. With levels less than 0.5 ng/ml, a correct
prediction of a very poor response (o2 oocytes) was
possible in 88% of cases. Levels of AMH greater than
0.5 ng/ml were not significantly correlated with clinical PRs.
AFC as indicator for ovarian reserve Soliman et al. 131
Their results showed that age and AMH levels are superior
parameters predicting ovarian response [23].
To conclude, basal AFC on day (2–5) before down-
regulation has a high predictive value in the prediction of
OR and it is a cheap and noninvasive test. In addition, age
is one of the best markers for ovarian reserve and for us it
seems that the age of 38 years is the cut-off point.
Moreover, a longer duration of infertility may be
indicative of a poor OR.
AcknowledgementsConflicts of interestThere are no conflicts of interest.
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132 Evidence Based Women’s Health Journal
Comparison between transfrontal and axial three-dimensional
ultrasound acquisition in the visualization of midline structures
of the fetal brainSherif M.M. Negm and Rasha A. Kamel
Department of Obstetrics and Gynecology, Faculty ofMedicine, Cairo University, Cairo, Egypt
Correspondence to Sherif M.M. Negm, El-Safa MedicalTower, 1 Higaz Square, El-Mohandessein, Giza, EgyptTel/fax: + 20 02 33386408;e-mail: [email protected]
Received 27 June 2012Accepted 15 July 2012
Evidence Based Women’s Health Journal
2012, 2:133–137
Objective
To compare the visualization of the midline structures of the fetal brain as well as
visualization of the fastigium of the fourth ventricle and the primary and secondary
vermian fissures obtained by three-dimensional (3D) multiplanar reconstruction of
volumes acquired from the axial plane with transfrontal 3D acquisition.
Study design
A prospective observational study.
Patients and methods
A total of 127 patients with a normal fetal anomaly scan between 18 and 24 weeks
participated in this study. Fetal brain volumes for the multiplanar evaluation were
obtained with the transcerebellar plane as the initial plane of acquisition, with the
incident ultrasound beam making an angle of about 451 with the cerebral midline. For
the transfrontal acquisition, the plane of the midsagittal fetal facial profile was obtained
with the ultrasound beam aligned with the frontal suture so as to utilize the metopic
suture as an acoustic window.
Results
The acquisition of the fetal brain in the axial plane was successful in 122 cases
(96.1%), whereas the transfrontal acquisition was successful in 106 cases (83.4%),
with a statistically significant difference between the two methods (P = 0.002).
Visualization of the median plane of the fetal brain by 3D multiplanar reconstruction
was adequate in 99 out of the 122 (81.1%) volumes, whereas 94 out of the 106
(88.7%) transfrontal acquisitions resulted in adequate midline images; the difference
between the two acquisition methods was not statistically significant (P = 0.12). There
was no statistically significant difference between the two acquisition methods in the
visualization of the fastigium of the fourth ventricle or the primary and secondary
vermian fissures, which were adequately visualized in 58/122 (47.5%) of the 3D
multiplanar reconstructed images and in 62/106 (60.8%) of the transfrontally acquired
volumes (P = 0.09).
Conclusion
Images of the midsagittal plane of the fetal brain obtained by 3D multiplanar
reconstruction of volumes acquired from axial plane are easier to acquire than the 3D
transfrontal approach and result in comparable image quality, with adequate
visualization of the cerebral midline as well as the main landmarks of the cerebellar
vermis.
Keywords:
fetal brain, midsagittal plane, multiplanar, three dimensional, three-dimensional
ultrasound, transfrontal
Evidence Based Women’s Health Journal 2:133–137& 2012 Evidence Based Women’s Health Journal2090-7265
IntroductionThe standard axial ultrasound views used to evaluate the
fetal brain do not adequately display the midline cerebral
structures, most notably the corpus callosum and the
cerebellar vermis [1], resulting in a low detection rate of
congenital anomalies involving these important struc-
tures [2,3]. Many authors have thus advocated the use of
the transfrontal plane, which is a sagittal section of
the fetal head using the metopic suture as an acoustic
window, to directly visualize the facial profile and
the midline fetal cerebral structure at the same
time [4–6]. However, this scanning plane is difficult to
obtain at midgestation as most fetuses are in a horizontal
line and thus obtaining the proper plane requires
considerable ability and, occasionally, transvaginal exam-
ination [7].
One of the many advantages of three-dimensional (3D)
ultrasound is its ability to manipulate a volume and obtain
planes that are different from the one used to acquire it.
For this reason, 3D ultrasound has been used in several
Original article 133
2090-7265 & 2012 Evidence Based Women’s Health Journal DOI: 10.1097/01.EBX.0000419244.02239.14
studies to obtain reconstructed midline views of the fetal
brain from volumes acquired from axial planes [8–10].
The aim of this study is to compare the visualization of
the midline structures of the fetal brain, obtained by 3D
multiplanar reconstruction of volumes acquired from axial
plane with transfrontal 3D acquisition.
Patients and methodsIn this prospective observational study, unselected single-
ton pregnancies between 18 and 24 weeks underwent a
fetal anomaly scan by one investigator only (S.M.M.N.)
according to the practice guidelines issued by the
International Society of Ultrasound in Obstetrics and
Gynecology [11]. Patients with medical disorders, multi-
fetal pregnancies as well as pregnancies with obvious fetal
structural anomalies were excluded from the study. Healthy
patients with an apparently normal anomaly scan were
asked to participate in this study. The departmental ethics
committee approved the study and an informed consent
was obtained from all recruited patients. Ultrasound
examinations were carried out with a Voluson 730 Pro
(GE Healthcare Austria GmbH & Co., Zipf, Austria) using
a transabdominal multifrequency volume probe (RAB
4–8L, GE Healthcare, Austria GmbH & Co., Zipf, Austria).
Fetal brain volumes for the multiplanar evaluation were
obtained with the fetal head in the axial plane according to
the method suggested by Fratelli et al. [12]. Briefly, after
optimization of the two-dimensional (2D) image with
harmonics set to medium or high, with the transcerebellar
plane as the initial axial plane of acquisition, the volume
was acquired with the incident ultrasound beam making an
angle of about 451 with the cerebral midline so as to avoid
acoustic shadowing of the skull base on the posterior fossa.
The 3D volume box was adjusted to include the entire
fetal head, the acquisition quality was set to maximum, the
sweep angle was set to 60–701, and the upper reference
line was set close to the anterior parietal bone. With this
method, boxes A, B, and C of the acquired multiplanar
images always corresponded to the axial, coronal, and
sagittal planes, respectively.
For the transfrontal acquisition, we used the method
described by Vinals et al. [13]. The plane of the midsagittal
fetal facial profile was obtained with the ultrasound beam
aligned with the frontal suture so as to utilize the metopic
suture as an acoustic window. Gentle manipulation of the
fetal head by the examiner was carried out when required
to bring the fetal head into a favorable position. Similar to
Figure 1
A three-dimensional multiplanar reconstructed images of the fetal brain acquired in the axial plane. The midsagittal view of the fetal brain is shown inthe C plane image (bottom left image), showing good visualization of the midline structures the fetal brain. The axial plane (A) shown in the upper leftimage is the acquisition plane. CM, cisterna magna; CSP, cavum septum pellucidum; F, fastigium of the fourth ventricle; PF, primary cerebellar fissure;SF, secondary cerebellar fissure; V, cerebellar vermis; 3V, third ventricle.
134 Evidence Based Women’s Health Journal
the previously described method, the 2D ultrasound image
was optimized so as to visualize the corpus callosum and
the cerebellar vermis with harmonics set to medium or
high. The 3D render box was adjusted to include the
entire fetal head, the acquisition quality was set to
maximum, and the sweep angle was set at 301.
For each fetus, at most two acquisitions per 3D technique
were obtained and the volumes with the least acoustic
shadowing were stored. The stored images were later
analyzed offline by either of the two authors (S.M.M.N.
or R.A.K.) on a computer using dedicated software (4D
view; GE Healthcare). Both authors have several years of
experience in the field of fetomaternal ultrasound and are
Consultants at the Fetal Medicine Unit at Cairo
University. The volumes were manipulated so as to
display the clearest image of the sagittal midline plane of
the fetal brain, mainly the corpus callosum, the cavum
septum pellucidum, the third ventricle, the cerebellar
vermis, and the cisterna magna. We defined the
visualization of the midsagittal plane as adequate when
all the anatomical landmarks were identified clearly
according to the guidelines set by the International
Society of Ultrasound in Obstetrics and Gynecology for
carrying out the fetal neurosonogram [14]. The ability to
visualize the main landmarks of the cerebellar vermis,
mainly the fastigium of fourth ventricle and the primary
and secondary vermian cerebellar fissures, was also
compared between images obtained by the two methods.
Statistical analysis
Normally distributed parameters are presented as mean ±
SD and non-normally distributed values are presented as
median (range). Normality of data were tested for all
continuous variables using the Shapiro–Wilk test. Catego-
rical variables were compared using the w2 or Fisher’s exact
test according to cell size. Nonparametric (continuous)
variables were compared using the Mann–Whitney U-test.
A P value less than 0.05 was considered as statistically
significant. Statistical analysis was carried out using
Microsoft Excel 2010 (Microsoft Corporation, Redmond,
Washington, USA) and Arcus Quickstat Biomedical version
1.0 (Research Solutions, Cambridge, UK).
ResultsA total of 127 patients were examined in this prospective
observational study. The patients had a mean age of 30.2
years (SD, 3.8; 95% CI, 29.5–30.9), a mean BMI of 24.6
(SD, 1.9; 95% CI, 24.2–24.9), and a mean gestational age of
21.3 weeks (SD, 1.4; 95% CI, 21.0–21.5). Ninety-seven
fetuses (76.4%) were in cephalic presentation, whereas the
remaining 30 (23.6%) were in breech presentation. The
acquisition of the fetal brain in the axial plane was
successful in 122 cases (96.1%), whereas the transfrontal
acquisition was successful in 106 cases (83.4%), with a
statistically significant difference between the two meth-
ods (P = 0.002). Table 1 shows that none of the patient or
the fetal characteristics had a statistically significant effect
on the successful acquisition in either method.
Both the 3D reconstructed images from the axially acquired
images as well as the transfrontal 3D images provided
detailed visualization of the midline structures of the fetal
brain (Figs 1 and 2) in the majority of cases. Visualization of
the median plane of the fetal brain by 3D multiplanar
reconstruction was considered adequate in 99 out of the
122 (81.1%) volumes acquired from the axial plane,
whereas 94 out of the 106 (88.7%) transfrontal acquisitions
resulted in adequate midline images; the difference
between the two acquisition methods was not statistically
significant (P = 0.12). There was no statistically significant
difference between the two acquisition methods in the
visualization of the fastigium of the fourth ventricle as well
as the primary and secondary vermian fissures, which were
adequately visualized in 58/122 (47.5%) of the 3D multi-
planar reconstructed images from the axial volumes and in
62/106 (60.8%) of the transfrontally acquired volumes
(P = 0.09). Images were considered adequate if the corpus
callosum could be seen clearly as an anechoic curved
structure with an echogenic defining contour overlying and
clearly differentiated from the sonolucent cavum septum
pellucidum. The contents of the posterior fossa, mainly the
cerebellar vermis as an echogenic well-defined structure
separated from the occipital bone by the sonolucent
cisterna magna, should also be seen. In the cases with
inadequate visualization of the midline cerebral structures,
shadowing by the cranial bones was the reason for the
poor image quality, with poor demarcation of the corpus
callosum from the underlying cavum septum pellucidum
resulting in a single comma-shaped anechoic structure or an
ill-defined posterior fossa.
DiscussionOne of the many advantages of 3D ultrasound is the ability
to store the acquired volumes for later offline analysis or
even send them to an expert in a different site for analysis
by telemedicine. With the aid of specialized software such
as 4D view, which we used in the current study, the
operator can navigate through a multiplanar display of the
volume to construct virtual 2D planes, which are difficult to
Table 1 Effect of the demographic variables on successful axial and transfrontal acquisition
Axial acquisition Transfrontal acquisition
Successful Failed P value Successful Failed P value
Patient age [mean (SD)] 30.1 (3.7) 30.0 (3.6) 0.54 30.0 (3.5) 30.2 (3.7) 0.67BMI [mean (SD)] 24.2 (1.9) 24.6 (2.0) 0.51 24.1 (1.6) 24.7 (1.8) 0.39Gestational age [mean (SD)] 21.1 (1.4) 21.4 (1.6) 0.35 21.0 (1.4) 21.2 (1.5) 0.56Cephalic presentation [N (%)] 94 (96.9%) 3 (3.1%) 0.37 82 (84.5%) 15 (15.5%) 0.55Breech presentation [N (%)] 28 (93.3%) 2 (6.7%) 24 (80%) 6 (20%)
Transfrontal vs. axial 3D of fetal brain Negm and Kamel 135
acquire using conventional 2D ultrasound such as the
midsagittal plane of the fetal brain. The use of postproces-
sing software such as speckle reduction filters (SRI) can
help reduce the tissue speckle pattern and enhance the
contrast resolution of the image.
In the present study, we were able to obtain a satisfactory
axial view of the fetal head in order to acquire a 3D
multiplanar volume in the majority of cases (96.1%),
whereas the direct midsagittal view required to acquire a
3D transfrontal volume was obtained in only 83.4% of
cases (P = 0.002), mainly because of the unfavorable
position of the fetal head that could not be manipulated
to carry out a proper acquisition, whereas the axial plane,
similar to the transthalamic plane used to measure fetal
head diameters, was more readily imaged.
Although images with greater detail could have been
obtained by transvaginal 3D acquisition as shown by Malinger
and Zakut [1], our goal was to try and incorporate fetal
neurosonography into the routine transabdominal midtrimes-
teric fetal anomaly scan. Furthermore, the transvaginal route
would not have been possible in patients with a breech fetus.
Fratelli et al. [12] studied the fetal brain using 3D
ultrasound using volumes acquired in the axial view with
an angle of 451 between the incident ultrasound beam and
the cerebral midline to avoid acoustic shadowing by the
skull base on the posterior fossa, which was the method
that we adopted in the present study. Their results showed
adequate visualization of the midsagittal plane of the fetal
brain in 83–87% of examined volumes. They also found
good interobserver agreement, with a k value of 0.70.
These results are similar to those found in the present
study, in which 81.1% of successfully acquired axial volumes
resulted in adequately visualized images of the midsagittal
plane of the fetal brain. Similar results were obtained by
Correa et al. [9], who studied the role of 3D ultrasound in
the assessment of the fetal brain and found that acceptable
cerebral multiplanar images were obtained in 92% of the
cases and that the median sagittal plane could be visualized
adequately in 85% of analyzed volumes.
Visentin et al. [15] used conventional 2D ultrasound by the
transfrontal view of the fetal head in midtrimester fetuses
to visualize the fetal brain in the midsagittal plane. They
were able to successfully obtain a transfrontal view in 89%
of cases, with good visualization of the midline structures of
the fetal brain.
Vinals et al. [13] compared visualization of the midline
cerebral structures obtained by 3D multiplanar imaging
using an axial acquisition plane with transfrontal 3D
acquisition. Measurement of the corpus callosum and
Figure 2
A three-dimensional transfrontal image of the fetal brain. The midsagittal view of the fetal brain is show in the A plane image (upper left image), whichis the same as the original acquisition plane. CM, cisterna magna; CSP, cavum septum pellucidum; F, fastigium of the fourth ventricle; PF, primarycerebellar fissure; SF, secondary cerebellar fissure; V, cerebellar vermis; 3V, third ventricle.
136 Evidence Based Women’s Health Journal
cerebellar vermis and visualization of the fourth ventricle
and the main vermian fissures were also compared. In their
study, the midsagittal plane could be obtained in 88 and
87% of the 3D multiplanar and transfrontal images,
respectively. They found a good correlation between the
two methods in the measurement of the corpus callosum
and cerebellar vermis diameters. However, the images
obtained by transfrontal acquisition were clearer and more
sharply defined than those obtained by the 3D multiplanar
method. Also, the primary and secondary fissures of the
cerebellar vermis could be detected in 26 and 13%,
respectively, of multiplanar images compared to 79 and
52%, respectively, of transfrontal analyses (Po0.0001).
They attributed the poorer quality of the 3D multiplanar
images mainly to acoustic shadowing by the petrous part of
the temporal bone, which frequently obscured the fetal
brain stem, fourth ventricle, and cerebellar vermis.
The results of Vinals et al. [13] are different from our
findings, where we found no statistically significant
difference between the two methods in the image quality
of the midsagittal plane of the fetal brain (P = 0.12) or in
the visualization of the primary and secondary vermian
fissures (P = 0.09). Our better results in terms of the
midsagittal images obtained by 3D multiplanar acquisi-
tion could be attributed to our use of the acquisition
method proposed by Fratelli et al. [12], which involves
using the transcerebellar plane instead of the transtha-
lamic plane as the initial plane of acquisition and with the
incident ultrasound beam making an angle of 451 with the
cerebral midline, thus minimizing the acoustic shadowing
of the skull base on the structures of the posterior fossa.
ConclusionImages of the midsagittal plane of the fetal brain obtained
by 3D multiplanar reconstruction of volumes acquired from
the axial plane are easier to acquire than the 3D
transfrontal approach and result in comparable image
quality, with adequate visualization of the cerebral midline
as well as the main landmarks of the cerebellar vermis.
AcknowledgementsConflicts of interestThere are no conflicts of interest.
References1 Malinger G, Zakut H. The corpus callosum: normal fetal development
as shown by transvaginal sonography. Am J Roentgenol 1993; 161:1041–1043.
2 Monteagudo A. Fetal neurosonography: should it be routine? Should it bedetailed. Ultrasound Obstet Gynecol 1998; 12:1–5.
3 Pilu G, Visentin A, Valeri B. The Dandy–Walker complex and fetal sono-graphy. Ultrasound Obstet Gynecol 2000; 16:115–117.
4 Visentin A, Pilu G, Falco P, Bovicelli L. The transfrontal view: a new approachto the visualization of the fetal midline cerebral structures. J Ultrasound Med2001; 20:329–333.
5 D’Addario V, Pinto V, Di Cagno L, Pintucci A. The midsagittal view of the fetalbrain: a useful landmark in recognizing the cause of fetal cerebral ven-triculomegaly. J Perinat Med 2005; 33:423–427.
6 Achiron R, Achiron A. Development of the human fetal corpus callosum:a high-resolution, cross-sectional sonographic study. Ultrasound ObstetGynecol 2001; 18:343–347.
7 Benn PA, Gainey A, Ingardia CJ, Rodis JF, Egan JFX. The fetal cerebellarvermis: normal development as shown by transvaginal ultrasound. PrenatDiagn 2001; 21:687–692.
8 Vinals F, Munoz M, Naveas R, Shalper J, Giuliano A. The fetal cerebellarvermis: anatomy and biometric assessment using volume contrastimaging in the C-plane (VCI-C). Ultrasound Obstet Gynecol 2005; 26:622–627.
9 Correa FF, Lara C, Bellver J, Remohı J, Pellicer A, Serra V. Examination of thefetal brain by transabdominal three-dimensional ultrasound: potential forroutine neurosonographic studies. Ultrasound Obstet Gynecol 2006;27:503–508.
10 Pilu G, Segata M, Ghi T, Carletti A, Perolo A, Santini D, et al. Diagnosis ofmidline anomalies of the fetal brain with the three-dimensional median view.Ultrasound Obstet Gynecol 2006; 27:522–529.
11 Salomon LJ, Alfirevic Z, Berghella V, Bilardo C, Hernandez-Andrade E, JohnsenSL, et al. Practice guidelines for performance of the routine mid-trimester fetalultrasound scan. Ultrasound Obstet Gynecol 2011; 37:116–126.
12 Fratelli N, Taddei F, Prefumo F, Franceschetti L, Farina G, Frusca T. Inter-observer reproducibility of transabdominal 3-dimensional sonography of thefetal brain. J Ultrasound Med 2009; 28:1009–1013.
13 Vinals F, Munoz M, Naveas R, Giuliano A. Transfrontal three-dimensionalvisualization of midline cerebral structures. Ultrasound Obstet Gynecol2007; 30:162–168.
14 Paladini D, Malinger G, Monteagudo A, Pilu G, Timor-Tritsch I, Toi A. Sono-graphic examination of the fetal central nervous system: guidelines for per-forming the ‘basic examination’ and the ‘fetal neurosonogram’. UltrasoundObstet Gynecol 2007; 29:109–116.
15 Visentin A, Pilu G, Falco P, Bovicelli L. The transfrontal view: a new approachto the visualization of the fetal midline cerebral structures. J Ultrasound Med2001; 20:329–333.
Transfrontal vs. axial 3D of fetal brain Negm and Kamel 137
Glycosylated hemoglobin level at 34 weeks in insulin-controlled
diabetic pregnancies, relation to fetal outcomeHoda Abdelaala, Mohamed A. Kasema, Abdelmeguid Alia
and Alaa M. Abd Elazemb
aDepartment of Obstetrics & Gynecology, Faculty ofMedicine, Cairo University, Cairo and bShebeen ElkomTeaching Hospital, Egypt
Correspondence to Hoda Abdelaal, Department ofObstetrics and Gynecology, Faculty of Medicine, CairoUniversity, Cairo, EgyptTel: + 012 2284 8993;e-mail: [email protected]
Received 10 November 2011Accepted 12 December 2011
Evidence Based Women’s Health Journal
2012, 2:138–141
Objective
To determine the role of glycosylated hemoglobin at 34 weeks’ gestation and onwards
in the prediction of fetal outcome in insulin-controlled diabetic pregnancies.
Design
Cohort study.
Setting
Kasr Al-Aini Hospital.
Participants and methods
A total of 50 singleton pregnant women on insulin treatment with gestational age
between 34 and 36 weeks were included. All women underwent ultrasound
fetometery, and glycosylated hemoglobin level at 34 weeks, amniotic fluid index,
placental maturation, and biophysical profile were determined. Doppler ultrasound was
also carried out. Follow-up was carried out for all women until delivery and neonates
were examined for body weight, APGAR scoring at 1 and 5 min, and blood glucose
level (adverse if <45 mg/dl).
Results
There was a statistically significant correlation between HbA1c and BMI, amniotic fluid
index, and neonatal outcomes. HbA1c of 7 or higher was found to be a cutoff value for
the prediction of prematurity, with area under curve of 91.7% (Fig. 2).
Conclusion
HbA1c may be a useful marker for prematurity in pregnant diabetic women and may
correlate with fetal outcome. For the antenatal care of diabetic mothers, it is
recommended is to maintain HbA1c less than 7% decrease fetal adverse outcome.
Keywords:
APGAR, glycosylated hemoglobin, maturity, pregnancy
Evid Based Women Health J 2:138–141& 2012 Evidence Based Women’s Health Journal2090-7265
IntroductionGestational diabetes (GDM) represents a significant health
risk for the mother and offspring during pregnancy, delivery,
and throughout life. Offspring of women with GDM are at
an increased risk for neonatal complications, in particular,
macrosomia, large for gestational age, respiratory distress,
prematurity, hypoglycemia, polyhydramnios, and death [1].
These offspring are also at a high risk for obesity, insulin
resistance, and type 2 diabetes (T2DM) [2]. Thus, the
diagnosis and appropriate management of GDM has the
potential to markedly reduce neonatal and maternal
morbidity and the burden of T2DM.
Glycosylated hemoglobin, as measured by hemoglobin A1C
(HbA1c), is used as a marker of glycemic control in patients
with type 1 diabetes (T1DM) and T2DM [2]. Notably, the
American Diabetic Association has recently recommended
that A1C higher than 6.5% may be used as a diagnostic
measure for T2DM and that women with A1C higher than
6.5% at their first prenatal visit be diagnosed with T2DM
rather than GDM [3]. In the nonpregnant diabetic
population, sustained high A1C is associated with increased
complications of diabetes [4]. Therefore, optimal A1C levels
in pregnancy should be defined by the level of increased risk
for adverse pregnancy outcomes. Elevated A1C may be an
attractive option for the identification of pregnant women at
a high risk for GDM, postpartum T2DM, and macrosomia or
delivering an large for gestational age infant. The aim of the
present study is to determine a role of glycosylated
hemoglobin at 34 weeks’ gestation and onwards in the
prediction of fetal outcome in insulin-controlled diabetic
pregnancies.
Patients and methodsThis prospective cohort study included 50 pregnant women
recruited from the Obstetric Outpatient Clinic and Depart-
ment of Obstetrics & Gynecology at Kasr Al-Aini Hospital.
We included singleton pregnant women on insulin treatment
with gestational age at the time of inclusion between 34–36
weeks. We excluded women on diet control or those with
medical disorders not related to diabetes such as Systemic
Lupus Erythematous, thyroid disorders, hypertension, and
preeclampsia.
138 Original article
2090-7265 & 2012 Evidence Based Women’s Health Journal DOI: 10.1097/01.EBX.0000419243.94615.e9
All women underwent ultrasound fetometery, and glycosy-
lated hemoglobin level at 34 weeks, amniotic fluid index,
placental maturation, and biophysical profile were deter-
mined. Doppler ultrasound was also carried out. Follow-up
was carried out for all women until delivery and neonates
were examined for body weight, APGAR scoring at 1 and
5 min, adverse neonatal outcome (when the APGAR score is
<7 at 5 min), death either intrauterine or early after birth,
neonatal weight more than 4.5 kg, presence of signs of respi-
ratory distress syndrome, and blood glucose less than 45 mg/dl.
Doppler study
Uterine, umbilical, and middle cerebral artery Doppler was
carried out by measurement of Doppler indices. The
pulsatility index (PI) was used as the test Doppler
parameter because PI describes the shape of the velocity
wave form much better. (a) Umbilical artery Doppler: All
patients were placed in a semirecumbent position with a left
lateral tilt, and then the uterine content was scanned to
select an area of amniotic cavity with several loops of cord.
When the screen showed at least three successive waveforms
of similar height, the image was frozen and the Doppler
umbilical artery pulsatility index was estimated. (b) Uterineartery Doppler: Doppler examination of the uterine arteries
was performed at the same time. Color Doppler was used to
identify the apparent crossing of the uterine and iliac vessels.
Uterine artery velocimetry was recorded just cranial of the
vessel ‘crossing’. Three even subsequent blood flow velocity
waveforms were used to calculate PI and to analyze the
presence or absence of an early diastolic notch.
Glycosylated hemoglobin
Whole blood was collected by a standard procedure
(1 cm). Heparin or edeta was used as an anticoagulant.
HbA1c was stable for 7 days at 2 – 81C. After preparing
the hemosylate, where the labile fraction is eliminated,
hemoglobins are retained by cation exchange resin,
HbA1c is specifically eluted after washing the hemoglo-
bin Aa + b fraction, and quantified by direct photometric
reading at 415 nm. Reference values were as follows:
(1) HbA1co6.3%: very good glycemic control.
(2) HbA1c between 6.3 and 7.1%: good glycemic control.
(3) HbA1c between 7.1 and 9%: poor glycemic control.
(4) HbA1c49%: poor glycemic control.
Statistical analysis
The data were coded, entered, and processed on a computer
using SPSS (version 16, IBM, New York, USA). Qualitative
data are presented as number and percentages whereas
quantitative data are presented as mean and SD. Student’s
t-test was used to assess the statistical significance of
the difference between two population means in a study
involving independent samples. A P-value was considered
significant if less than 0.05.
The Pearson correlation coefficient was used to determine
the relation between the quantitative parameters. Logistic
regression analysis was used to assess the effect of
quantitative parameter on an outcome. ROC curve was used
to assess the sensitivity and specificity of factor in predicting
the outcome.
ResultsThe present study included women ranging in age from 19 to
35 years, mean ± SD (26.94 ± 4.497); the patient’s BMI
ranged from 21 to 33, mean ± SD (25.04 ± 3.110). Table 1
shows other characteristics of our participants. No statistically
significant relation was found between HbA1c and age of the
studied patients, whereas there was a statistically significant
correlation between HbA1c and BMI, amniotic fluid index,
and neonatal outcomes (Table 2). HbA1c of 7 or higher was
found to be a cutoff value for prediction of prematurity with
an area under curve of 91.7% (Fig. 1); also, this cutoff value
was used for the prediction of polyhydramnios, macrosomia,
neonatal hypoglycemia (Fig. 2), respiratory distress syndrome,
and cesaerean section rate (with area under the curve of 77.5,
72.6, 98.3, 98.3, and 87.1, respectively).
DiscussionIn the USA, the prevalence of GDM may range from 1 to
14% of pregnancies [3]. GDM generally has few symptoms
and it is most commonly diagnosed by screening during
pregnancy. Diagnostic tests detect inappropriately high
levels of glucose in blood samples [5].
Glycosylated hemoglobin, as measured by HbA1c, is used as
a marker of glycemic control in patients with T1DM and
Table 1 Descriptive statistics for the parameters studied
Minimum Maximum Mean SD
Insulin dose 30 90 41.80 13.92FW (kg) 1.6 4.9 3.09 0.81AFI 6 28 17.40 5.47BPD 4 8 7.40 1.01UTA PI 0.6 1.2 0.78 0.14MCA PI 1.4 1.95 1.81 0.17UMA PI 0.81 1.25 0.92 0.13HbA1c 5.8 13 8.17 1.98FBS 70 135 96.46 19.762hPPS 120 280 186.08 59.72APGAR1 4 8 6.65 1.41APGAR5 5 10 7.87 1.84Birth weight (kg) 2 5.2 3.30 0.74Glucose 25 85 49.06 20.36Delivery age (weeks) 35 38 36.69 1.19
2hPPS, two hours post prandial blood sugar; AFI, amniotic fluid index;BPD, biparietal diameter; FBS, fasting blood sugar; FW, fetal weight;MCA, middle cerebral artery; PI, pulsatility index; UMA, umbilical artery;UTA, uterine artery.
Table 2 Correlation between HbA1c with age, BMI, AFI, BMI
fetal weight, birth weight, neonatal glucose, and APGAR5
HbA1c
R P-value
Age 0.244 0.088BMI 0.432** 0.002AFI 0.301* 0.034FW (kg) 0.426** 0.003Birth weight (kg) 0.308* 0.033Neonatal glucose – 0.552** 0.000APGAR5 – 0.689** 0.000
AFI, amniotic fluid index; FW, fetal weight.*Correlation is significant at the 0.05 level (two-tailed).**Correlation is significant at the 0.01 level (two-tailed).
Glycosylated Hb and fetal outcome Aal et al. 139
T2DM [2]. In the present study, we aimed to evaluate its
use as a marker in gestational diabetic women at 34 weeks
and follow them up. Interestingly, the present study
observed a positive relation between glycosylated hemoglo-
bin and adverse fetal outcome; that is, when HbA1c more
than 7% at 34 weeks, there was increase in the frequency of
adverse fetal outcomes including respiratory distress syn-
drome, macrosomia, polyhydramnios, prematurity, and neo-
natal hypoglycemia [1].
The results of the current study showed that the
sensitivity of HbA1c more than 7% for predicting
polyhydramnios was 100% and the specificity was
57.14%. The incidence of large for gestational age was
38% and this was in agreement with the result of Yang
et al. [6], who reported a 40% in Pregnancy Outcomes of
Births in Nova Scotia from 1988 to 2002 in Women with
and Without Pregestational Diabetes.
The study also found a highly statistically significant
positive relation between HbA1c with fetal weight and a
significant positive relation with birth weight (P = 0.003
and 0.033, respectively), which was in agreement with
Katon et al [7], who reported that the association of A1C
and birth weight was stronger when antepartum A1C was
measured after a diagnosis of GDM (at 34 weeks).
The results of the current study showed that the sensitivity
of HbA1c more than 7% for predicting macrosomia was 82%
and the specificity was 63%. In this study, the incidence of
hypoglycemia was 40% and there was a highly statistically
significant relation (Po0.005) between HbA1c and
neonatal glucose level, yielding an area under the curve
of 98.3. This was in agreement with Arumugam and Abdul
Majeed [8], who reported that HbA1c levels in late
pregnancy are good predictors of hypoglycemia in the
newborn, yielding an area under the curve of 0.99. In
simple terms, what this means is that if there were two
babies who were randomly selected, one with hypoglycemia
and one without, the probability that the hypoglycemic
neonate would have shown an abnormally high maternal
HbA1c would be around 99% [9]. In this study, there was
no statistically significant relation between HbA1c and
Doppler and this in agreement with Pietryga et al. [10], who
concluded that there was no correlation between long-term
maternal glycemic control (HbA1c) and changes in blood
flow velocity in placental circulation in pregnancy compli-
cated by diabetes mellitus.
ConclusionHbA1c may be a useful marker for prematurity in
pregnant diabetic women. For the antenatal care of
diabetic mothers, we recommend maintaining HbA1c less
than 7% to decrease fetal adverse outcome. For further
confirmation of the above results, we need to study a
larger number of patients.
AcknowledgementsConflicts of interestThere are no conflicts of interest.
References1 Vohr BR, Boney CM. Gestational diabetes: the forerunner for the develop-
ment of maternal and childhood obesity and metabolic syndrome? J MaternFetal Neonatal Med 2008; 21:149–157.
2 Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM,Sacks DB. Tests of glycemia in diabetes. Diabetes Care 2004; 27:1761–1773.
Figure 1
HbA1C
0 20 40 60 80 100
0
20
40
60
80
100
100-Specificity
Sens
itivi
ty
ROC curve for the prediction of prematurity with a cutoff point of 7 andarea under curve of 91.7.
Figure 2
HbA1C
0 20 40 60 80 100
0
20
40
60
80
100
100-Specificity
Sens
itivi
ty
ROC curve for the prediction of neonatal hypoglycemia with a cutoffpoint of 7 and area under curve of 98.3.
140 Evidence Based Women’s Health Journal
3 American Diabetes Association. Diagnosis and classification of diabetesmellitus. Diabetes Care 2011; 34 (Suppl 1): S62–S69.
4 Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ. Translatingthe A1C assay into estimated average glucose values. Diabetes Care 2008;31:1473–1478.
5 Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS.Effect of treatment of gestational diabetes mellitus on pregnancy outcomes.N Engl J Med 2005; 352:2477–2486.
6 Yang J, Cummings EA, O’Connell C, Jangaard K. Fetal and neonataloutcomes of diabetic pregnancies. Obstet Gynecol 2006; 108 (3 I):644–650.
7 Katon J, Williams MA, Reiber G, Miller E. Antepartum A1C, maternal diabetesoutcomes, and selected offspring outcomes: an epidemiological review.Paediatr Perinat Epidemiol 2011; 25:265–276.
8 Arumugam K, Abdul Majeed N. Glycated haemoglobin is a good predictor ofneonatal hypoglycaemia in pregnancies complicated by diabetes. Malays JPathol 2011; 33:21–24.
9 Obuchowski NA. Receiver operating characteristic curves and their use inradiology. Radiology 2003; 229:3–8.
10 Pietryga M, Brazert J, Wender-Ozegowska E, Dubiel M, Gudmundsson S.Placental Doppler velocimetry in gestational diabetes mellitus. J Perinat Med2006; 34:108–110.
Glycosylated Hb and fetal outcome Aal et al. 141
Evaluation of the atherogenic role of lipoproteins and oxidized
low-density lipoprotein in pre-eclampsiaYasser H. Shaabana, Fatma Aletebib, Manal Helald and Walid Saberc
Departments of aClinical and Chemical Pathology,bInternal Medicine, cObstetrics and Gynecology,Faculty of Medicine, Cairo University, Cairo, Egypt anddDepartment of Obstetrics and Gynecology, KingAbdulAziz University, Saudi Arabia
Correspondence to Yasser H. Shaaban, MD,Department of Chemical Pathology, Faculty ofMedicine, Cairo University, Cairo, EgyptE-mail: [email protected]
Received 16 March 2012Accepted 14 April 2012
Evidence Based Women’s Health Journal
2012, 2:142–146
Objectives
The aim of this study was to evaluate the levels of lipid parameters and oxidized
low-density lipoprotein (ox-LDL) and compare them in normal and pre-eclamptic
pregnant women as well as to determine the relative risk of developing pregnancy-
induced hypertension disorders in patients in whom ox-LDL levels are elevated.
Participants and methods
Singleton pregnant women (18–38 years old) were recruited and divided into two
groups: 26 women with pre-eclampsia and 21 women with normal uncomplicated
pregnancies. Blood and urine samples were taken from all the participants; different
lipid parameters including triglycerides, cholesterol, high-density lipoprotein
cholesterol, and low-density lipoprotein cholesterol were determined. In addition,
urine protein and ox-LDL were assessed.
Results
The two groups studied were matched in terms of maternal age, BMI, and gestational
age. Pre-eclamptic patients had significantly higher blood pressure compared with the
women with normal pregnancies (control). Of the measured lipid parameters,
significantly higher values of triglycerides, very low-density lipoprotein-C, and ox-LDL
were found in the women in the pre-eclampsia group compared with the control group
(P = 0.003 and 0.049, respectively). None of the measured lipid parameters showed
a significant association when correlated to ox-LDL. The calculated cut-off for ox-LDL
in our study was 36 ng/ml. Patients with high ox-LDL levels during pregnancy had 1.7
times higher risk for developing pre-eclampsia than women with normal pregnancies.
Conclusion
Dyslipidemia and oxidative stress may play an important role in the pathogenesis of
pregnancy-induced hypertensive disorders. Thus, our findings may be relevant for
understanding the pathophysiology of pre-eclampsia and showed that there is a need
for further research work to establish the role of lipid-modifying regimens, lifestyle
modifications, and antioxidant therapy to reduce the risk of developing such disorders.
Keywords:
dyslipedemia, lipids, oxidized low-density lipoprotein, pre-eclampsia, pregnancy
Evid Based Women Health J 2:142–146& 2012 Evidence Based Women’s Health Journal2090-7265
IntroductionPre-eclampsia is a common multisystem pregnancy dis-
order in which the diagnosis is made on the basis of the
presence of hypertension and proteinuria, affecting 3–5%
of all pregnant women. Pre-eclampsia occurs de novo in
late pregnancy after the 20th week of gestation, and severe
pre-eclampsia may be a serious threat to the mother
and the fetus. This disorder is a major cause of prenatal
and maternal morbidity and mortality worldwide [1].
The etiology of pre-eclampsia is still unknown and mul-
tiple factors have been implicated in its pathogenesis.
Metabolic syndrome, especially insulin resistance, and
pre-eclampsia have been well examined in previous re-
search [2,3]. Insulin resistance is common in pregnancy,
as are aberrant lipid metabolism, higher fasting glucose
level, and increased insulin secretion. These metabolic
changes are likely to have evolved to fulfill the metabolic
demands of a growing fetus, but these changes are aug-
mented in pre-eclampsia [4].
Previous studies have shown that in pre-eclampsia,
plasma lipids increase markedly beyond the levels found
in normal pregnancies [5,6]. It has been proposed that
such lipid changes may play a role in the endothelial
damage characteristic of pre-eclampsia. Given the phy-
siological role of gestational hyperlipidemia in supplying
both cholesterol and triglycerides to the rapidly develop-
ing fetus, it is conceivable that pregnancies complicated
by intrauterine growth retardation show abnormal lipo-
protein metabolism in an attempt to compensate for the
placental insufficiency. This mechanism has been pro-
posed to be responsible for the higher triglyceride concen-
trations observed in women with pre-eclampsia [7].
Diffuse vascular endothelial dysfunction, secondary to
oxidative stress, is an important pathological characteristic
142 Original article
2090-7265 & 2012 Evidence Based Women’s Health Journal DOI: 10.1097/01.EBX.0000415828.84622.0c
of pre-eclampsia. Oxidative conversion of low-density
lipoproteins (LDLs) into oxidized-LDL (ox-LDL) is
considered an important step in the transformation of
macrophages into lipid-laden foam cells destined to
develop into early atherosclerotic-like lesions [8].
Small dense LDL is also increased in the plasma of
women with pre-eclampsia. Small dense LDLs are more
susceptible to oxidation, resulting in the generation of ox-
LDL, which can bind to the lectin-like oxidized-LDL
receptor-1 (LOX-1) on endothelial cells. LOX-1 is a type
II membrane protein cell surface receptor found on
endothelial cells, vascular smooth muscle cells, and
monocyte macrophages. LOX-1 is expressed in athero-
sclerotic lesions in humans and has also been shown to be
elevated in hypertensive rats [9]. LOX-1 is responsible
for the binding, uptake, and degradation of ox-LDL. One
recent study has reported elevated LOX-1 expression in
the placenta of women with pre-eclampsia. However, the
expression, regulation, and significance of LOX-1 in the
maternal systemic vasculature of pre-eclampsia remain
unknown [10].
The aims of the present study are to measure the serum
levels of cholesterol, triglyceride, high-density lipoprotein
(HDL), LDL, and ox-LDL in pre-eclamptic pregnancy
and to compare them with those in normal pregnancy.
Participants and methodsThe present study was conducted from December 2009
to January 2011 among women with pre-eclampsia ac-
cording to the 10 current American College of Obste-
tricians and Gynecologists guidelines (American College
of Obstetricians and Gynecologists, 1996), which defined
pre-eclampsia as sustained pregnancy-induced hyperten-
sion with proteinuria. Pre-eclampsia was defined as per-
sistent (Z6 h) blood pressure of at least 140/90 mmHg
occurring after 20 weeks of gestation. Proteinuria was
defined as a urine protein concentration of 30 mg/dl or
higher (or 1 + on a urine dipstick or higher) in at least
two random specimens collected at least 4 h apart.
Two groups of 26 women with pre-eclampsia and 21 con-
trols with uncomplicated pregnancies matched for age,
gestational age, weight, and BMI were recruited. We ex-
cluded women with pregnancies associated with diabetes
mellitus, hepatic, renal, metabolic, cardiovascular dis-
eases, chronic or transient hypertension, thyrotoxicosis,
and hemophilia from our study. Also, pregnant women
with a previous history of gestational diabetes or those on
chronic medications were excluded from the study.
Data and sample collection
During participants’ antenatal care visits, we administered
structured interview questionnaires to collect information
on maternal sociodemographic, medical, reproductive, and
lifestyle characteristics. All interviews were conducted in
Arabic. BMI and the measure of adiposity were calculated
as weight (kg) divided by height (m2). Nonfasting blood
samples were collected in dry 10 ml vacutainer tubes
during the visit. Specimens were centrifuged at 3000g;
serum was separated and frozen at – 701C until analysis.
Analytical methods
Serum cholesterol and triglyceride concentrations were
measured enzymatically using assays on a Hitachi 917
chemistry analyzer (Roche Diagnostics, Berlin, Germany)
with a colorimetric procedure. HDL-C was assayed using
a homogenous enzymatic assay on a Hitachi 917
chemistry analyzer (Roche Diagnostics). LDL-cholesterol
(LDL-C) was calculated using the Friedewald formu-
la [11]. From the previous assays, the HDL/LDL and
cholesterol/HDL ratios were calculated. Plasma ox-LDL
concentrations were measured using commercial ELISA
assay kits (Immundiagnostik AG, Bensheim, Germany).
Statistical analysis
All analyses were performed using SPSS statistical soft-
ware version 10 (IBM, Chicago, Illinois, USA). All contin-
uous variables were presented as mean ± SD. All reported
confidence intervals were calculated at the 95% level.
Differences between groups were evaluated using Stu-
dent’s unpaired t-test and, when a variable was not
normally distributed, the Mann–Whitney U-test and
Wilcoxon W-tests were used. The relationship between
the variable was explored using the Pearson correlation
test. The association of ox-LDL with the maternal plasma
lipid profile was estimated using Spearman’s correlation
coefficients. The cutoff for ox-LDL was estimated using
the receiver operating characteristic (ROC) curve, area
under the curve, and the best sensitivity/specificity was
determined to calculate the cutoff. Logistic regression
procedures were used to calculate odds ratios and 95%
confidence intervals (CIs). To estimate the relative
association between pre-eclampsia and levels of maternal
ox-LDL, we categorized each study group into Healthy and
Cases on the basis of the level of the ox-LDL cut-off value
determined by the ROC curve.
ResultsThe demographic and clinical characteristics of pre-
eclampsia cases and controls are shown in Table 1. The
two groups studied were matched for maternal age
(18–38 years old), BMI, and gestational age at sampling.
Systolic and diastolic blood pressures were significantly
higher in women with pre-eclampsia (mean 163 and 105,
respectively) than those in the control group (mean 122
and 77, respectively) (Po0.001). Infants of pre-eclamp-
tic women had significantly lower Apgar scores for their
pregnancy outcomes when compared with those of
women with normal pregnancies.
Pregnant women with a complication of pre-eclampsia
had significantly higher mean triglyceride and very low-
density lipoprotein-C (VLDL-C) concentrations, relative
to the control group (P = 0.003 and 0.049, respectively).
In contrast, there were no significant differences in the
mean concentrations of total cholesterol, HDL-C and
LDL-C, and risk ratios between the cases and the
Oxidized-LDL in pre-eclampsia Shaaban et al. 143
controls (P40.05) as determined using the t-test as
shown in Table 2. Significantly higher ox-LDL values
were found in the pre-eclampsia group compared with
the control group using the Mann–Whitney U-test
(P = 0.044).
We next examined the correlations between maternal
plasma ox-LDL concentrations and lipid profile for pre-
eclampsia cases and controls Table 3. Ox-LDL concen-
trations were nonsignificantly positively correlated
with cholesterol (r = 0.043) and triglycerides (r =
0.072) (P40.05) in both pre-eclampsia cases and the
controls. Ox-LDL concentrations were nonsignificantly
inversely correlated with HDL-C (r = – 2.26) and LDL-C
(r = – 0.023) (P40.05). The calculated cut-off value for
ox-LDL was 36 ng/ml.
Ox-LDL levels were higher in women with pre-eclampsia
than those of the women in the control group. The overall
risk odds ratio was 1.750 (CI ranging from 0.364 to 8.424);
the ratio was 1.375 for the cases, with CI ranging from
0.547 to 3.459, and 0.786 for the healthy controls, with CI
ranging from 0.405 to 1.525 (Table 4 and Fig. 1).
DiscussionExperimental models indicated that increased ox-LDL is
capable of inducing many endothelial changes of poten-
tial relevance to pre-eclampsia [12]. However, it remains
unclear whether circulating ox-LDL is increased in pre-
eclampsia. Increased autoantibodies to an epitope of ox-
LDL, which is considered an indirect marker of ox-LDL,
have been found in women with pre-eclampsia relative to
those with a normal pregnancy [13], although negative
reports also exist [14,15]. The role and status of serum
lipids and ox-LDL in pregnant women are still being
discussed. The aims of the present study are to measure
the serum levels of cholesterol, triglyceride, HDL, LDL,
and ox-LDL in women with pre-eclampsia and to com-
pare these with those of women with normal pregnancies.
In the present study, there was no significant difference
(P40.05) in the serum levels of cholesterol, HDL-C,
LDL-C, and risk ratios between women with pre-
eclamptic pregnancies and those with normal pregnancies.
Our results are in agreement with those of some studies
[6,16], but not with other research works that have
reported significant increases in cholesterol, HDL-C, and
LDL-C [17,18]. These findings may be because of
differences in races and nutrition status. It should be
noted that all blood samples were taken from preeclamp-
tic women at their entry to Obstetrics and Gynecology
department to avoid any possible effect of medications on
the results of our study.
Significantly higher values (Po0.05) triglycerides and
VLDL-C were found in the pre-eclampsia group when
compared with normal pregnant women. Some previous
studies showed that the most significant damage in the
lipid profile in normal pregnancy is serum hypertriglycer-
idemia, which may be as high as two- to three-fold in the
third trimester compared with the levels in nonpregnant
women. The principal modulator of this hypertriglycer-
idemia is estrogen as pregnancy is associated with hyper-
estrogenemia. Estrogen induces hepatic biosynthesis of
endogenous triglycerides, which is carried by VLDL-C.
This process may be modulated by hyperinsulinism found
in pregnancy. Serum triglyceride and VLDL-C concentra-
tions were also found to increase significantly more in
toxemia of pregnancy in our study, which is in agreement
with the findings of many workers [17,19]. The above-
mentioned associations along with increased endothelial
triglyceride accumulation may result in endothelial cell
dysfunction in gestosis. Increased triglycerides, found in
pregnancy-induced hypertension, is likely to be deposited
in predisposed vessels, such as the uterine spiral arteries,
and contributes to endothelial dysfunction, both directly
and indirectly, through the generation of small, dense
LDL. Moreover, this hypertriglyceridemia may be asso-
ciated with hypercoagulability [20].
The values of ox-LDL in our study were significantly
increased (Po0.05) in pre-eclamptic women than in
normal pregnancies. Oxidation of LDL is commonly
believed to be essentially involved in the pathogenesis of
atherosclerosis, which is known to be the primary cause
of cardiovascular disease and stroke. Recent studies
have reported that ox-LDL impairs trophoblast invasion
in vitro, suggesting its role in the regulation of uterine
spiral artery remodeling in vivo [21]. Reduced trophoblast
invasion and atherosclerotic placental changes, described
as ‘acute atherosis’, are hallmarks in the pathogenesis of
pre-eclampsia and intrauterine growth retardation. Some
efforts have been made to evaluate ox-LDL levels in PE,
which have yielded inconsistent data: although in two
studies the ox-LDL concentration was found to be
significantly increased in comparison with normal healthy
pregnant controls [22,23], one research group did not find
a significant difference, but reported a 2.9-fold increased
risk for PE in women who had elevated ox-LDL
levels [24]. Only the group of Raijmakers et al. [25]
reported lower ox-LDL concentrations in PE.
None of the lipid and lipoprotein parameters showed
a significant association (P40.05) with ox-LDL, while
total cholesterol, triglycerides, and VLDL-C showed posi-
tive correlations with ox-LDL, maternal serum LDL-C
and HDL-C showed negative correlations. In one re-
search work [24], lipid parameters showed significant
Table 1 Demographic and clinical data of the studied groups
Mean ± SD
Items
Pre-eclampsia
groupControlgroup
P value(t-test)
Maternal age (years) 34.2 ± 2.3 32.1 ± 2.1 0.78BMI (kg/m2)Gestational (age/weeks) 27.2 ± 5.4Apgar score (min)
1 5.1 ± 1.2 NA5 7.8 ± 1.4 NA
Systolic BP (mm/Hg) 163.7 ± 13.8 122 ± 3.5 o0.001Diastolic BP (mm/Hg) 105 ± 10 77 ± 4.3 o0.001
BP, blood pressure.
144 Evidence Based Women’s Health Journal
associations with ox-LDL; this controversy results with
our findings may have been because of difference in
number of participants. The ROC curve constructed for
the estimation of the cut-off for ox-LDL in pre-eclampsia
was 36 ng/ml in our study.
In the present study, it was found that women with
increased ox-LDL concentrations had a 1.7-fold increased
risk of pre-eclampsia, compared with women who had
lower ox-LDL levels. Our results are in agreement with
those of some research works [24,26] and some results of
autoantibodies to ox-LDL (an indirect marker of in-vivo
ox-LDL) from cross-sectional case–control studies [13,27].
However, there has been only one published negative
report on maternal plasma ox-LDL concentrations in
relation to the risk of developing pre-eclampsia [25]. In
that study, women with pre-eclampsia had lower ox-LDL
concentrations than gestational-age-matched normoten-
sive pregnant controls. The authors attributed this inverse
association to the higher levels of autoantibodies to
ox-LDL, which might be responsible for the rapid
clearance of ox-LDL.
ConclusionCompared with normal pregnant women with similar
gestational age and BMI, with no significant difference in
maternal age, we observed that pre-eclamptic women had
higher blood pressure and increased triglycerides, VLDL-
C, and ox-LDL during pregnancy. Increased ox-LDL in
pregnancy is associated with a higher risk of devolving
pregnancy-induced hypertensive diseases. Our results
confirm the role of dyslipedemia and oxidative stress in
the pathogenesis of pregnancy-induced hypertensive
disorders. There is a need for further research work to
establish the role of diet, lifestyle modifications, and
antioxidant therapy to reduce the risk of development of
such disorders.
Table 3 Correlations of oxidized low-density lipoprotein with
different lipid parameters in both the groups (Spearman’s
correlation)
Oxidized-LDLn = 27
Parameters Correlation coefficient r P value
Total cholesterol 0.043 0.830Triglycerides 0.072 0.719HDL-C – 2.26 0.258LDL-C – 0.023 0.908
C, cholesterol; HDL, high-density lipoprotein; LDL, low-densitylipoprotein.
Table 4 Risk estimation by odds ratios and 95% confidence
interval of pre-eclampsia according to oxidized low-density
lipoprotein subgroups
95% confidence interval
Groups Odds ratio Lower Upper
Pre-eclampsia/control 1.750 0.364 8.424For cohort odds Cases
(pre-eclampsia/control)1.375 0.547 3.459
For cohort odds Healthy(pre-eclampsia/control)
0.786 0.405 1.525
Figure 1
Receiver operating characteristic (ROC) curve for the oxidized low-density lipoprotein. Area under the curve = 0.267, 95% confidenceinterval = 0.05–0.484, Cutoff (ox-LDL) = 36 ng/ml (40% sensitivity and50% specificity).
Table 2 Lipid parameters and oxidized low-density lipoprotein values of the studied groups
Mean ± SD
Items Pre-eclampsia group Control group P value (t-test)
Total cholesterol (mg/dl) 179.25 ± 55.243 186.64 ± 45.502 0.718Triglycerides (mg/dl) 207.69 ± 84.467 107.64 ± 69.618 0.003VLDL (mg/dl) 41.538 ± 16.893 21.528 ± 13.924 0.061HDL-C (mg/dl) 44.31 ± 9.555 46.45 ± 5.484 0.510LDL-C (mg/dl) 89.56 ± 51.673 118.64 ± 40.562 0.131Cholesterol/HDL ratio 4.044 ± 5.782 4.018 ± 8.297 0.621LDL/HDL ratio 2.02 ± 5.408 2.554 ± 7.396 0.172Ox-LDL (ng/ml) 12.50b ± 198.654 0.00b ± 108.838 0.044a
C, cholesterol; HDL, high-density lipoprotein; LDL, low-density lipoprotein; ox-LDL, oxidized-LDL; VLDL, very low-density lipoprotein.aMann–Whitney U-test.bMedian concentrations.
Oxidized-LDL in pre-eclampsia Shaaban et al. 145
AcknowledgementsConflicts of interestThere are no conflicts of interest.
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