Doctoral Degrees (Obstetrics and Gynaecology)
Permanent URI for this collection
Browse
Browsing Doctoral Degrees (Obstetrics and Gynaecology) by Title
Now showing 1 - 20 of 20
Results Per Page
Sort Options
- ItemComparing the diagnosis of gestational diabetes using the oral glucose tolerance test and a designed breakfast in a randomised, cross-over trial(Stellenbosch : Stellenbosch University, 2017-12) Marais, Colin; Hall, David Raymond; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.ENGLISH ABSTRACT: Objective This study compared a standardised, user-friendly designed breakfast (DB) to the 75g OGTT, comparing venous and capillary glucose values for the diagnosis of gestational diabetes. Methods 6 prospective, randomised, cross-over trial comparing the gold standard OGTT to a designed breakfast glucose profile (DBGP) in the diagnosis of gestational diabetes, was performed from March to December 2015. Fifty-one patients, attending the high-risk antenatal clinic at Tygerberg Hospital, were randomised to OGTT or DBGP at baseline. One week later, before intervention, the alternative test was performed. Fasting and 2-hour, venous and capillary values were measured. Patients qualified for screening on risk factors: previous gestational diabetes, previous unexplained intra-uterine death, previous macrosomic baby, booking BMI >40 kg/m2, age >40 years, affected first degree relative, susceptible family origin (Asiatic), acanthosis nigricans and polycystic ovarian syndrome. Results Fasting and 2-hour capillary glucose values measured during the OGTT correlated significantly with laboratory venous samples (Pearson's 0.74; p <0.001 at both time intervals). The 2-hour capillary glucose values obtained for the DB showed satisfactory correlation to the current gold standard OGTT (Pearson's 0.54; p <0.001). Conclusions The designed breakfast glucose profile provides a user-friendly, sufficiently accurate, promising alternative to diagnose GDM that deserves further investigation.
- ItemA comparison of three spermatozoa selection techniques for Intracytoplasmic Sperm Injection (ICSI) using swim-up, Cumulus Oophorus Model and PICSI ® Dish(Stellenbosch : Stellenbosch University, 2015-12) Rijsdijk, Michelle; Franken, D. R.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: Introduction: Spermatozoa selection for Intracytoplasmic Sperm Injection (ICSI) is a paramount factor in the outcome of a fertility treatment cycle. Nature has perfected the selection process by using the cumulus matrix to select spermatozoa that are morphologically and genetically normal. Aim: To determine which method of semen preparation delivers the best results in terms of spermatozoa selection for ICSI. Methods: Patients were randomized into 3 groups of spermatozoa selection techniques namely the routine swim-up or density gradient, the Cumulus Model or the PICSI® dish (hyaluronic acid). The prepared collected spermatozoa were used to make slides to record the percentage of normal spermatozoa (morphological staining), the capacitational status (chlorotetracycline test), chromatin packaging quality (chromomycin A3 (CMA3) staining) and the DNA quality (acridine orange staining). These results were then compared to the fertilization, cleavage, pregnancy and implantation rates of the patients used in the study. Results: All three groups displayed improvements in morphology, capacitational ability, chromatin packaging quality and DNA quality (or fragmentation). There was no significant difference in pregnancy rates between the groups and no difference in implantation rates. The PICSI® group did however show a significant improvement in the chromatin packaging quality, only if the baseline values were low. Conclusions: All 3 groups of spermatozoa selection techniques showed improvements in spermatozoa quality. The swim-up/gradient group showed a statistical improvement in the fertilization rate when compared to the cumulus and PICSI® groups. PICSI® showed a greater improvement in selected spermatozoa parameters when baseline values for CMA3 were low.
- ItemThe contextual quality of life of women with cervical cancer in the Western Cape, South Africa.(Stellenbosch : Stellenbosch University, 2018-12) Du Toit, George Campbell; Kruger, T. F.; Stellenbosch University. Faculty of Medicine and Health Science. Dept. of Department of Obstetrics and Gynaecology.ENGLISH ABSTRACT: Please refer to full text for abstract
- ItemThe cost effective IVF strategies in assisted reproduction technology programmes (art)(Stellenbosch : Stellenbosch University, 2016-12) Matsaseng, Thabo; Kruger, T. F.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.CHAPTER I Understanding the physiology of oocyte(s) recruited, selected and retrieved in a cycle of assisted reproductive technology (ART) is fundamentally important towards the development of the embryo with great potential for conception and live birth. This is discussed in detail. More important is the interpretation and utilization of the scientific evidence in this chapter to explore less expensive methods of optimizing oocyte quality in mild ovarian stimulation in vitro fertilization (IVF). CHAPTER II Clomiphene citrate (CC) is an inexpensive and safe drug that can be used alone or in combination with gonadotropins in IVF. Clinical outcomes in different IVF treatments using CC were reviewed and discussed in detail. The major concern regarding CC in ART is the risk of premature luteinizing hormone (LH) surge with subsequent detrimental effect on the oocyte quality. This issue is discussed with outlined strategies (inexpensive) to minimize the risk. CHAPTER III The effective methods to prevent premature LH surge in ART include gonadotropin releasing hormone antagonists (GnRHa) and gonadotropin releasing hormone agonists (GnRH). But these methods are expensive and unaffordable in resourcelimited countries. We therefore performed a randomised controlled trial to evaluate a simple method of prolonged usage of CC as a strategy to prevent premature LH surge in ART treatment. The protocol is described in detail. The trial showed that prolonged usage of CC did not suppress premature LH surge in mild ovarian stimulation ART. But it motivated us to explore other inexpensive strategies for lowering the risk of premature LH surge such as pre-treatment with oral contraceptives, the use of tamoxifen and the use of progesterone during ovarian stimulation. CHAPTER IV Stellenbosch University https://scholar.sun.ac.za In our endeavour to explore strategies to make ART accessible, a public-private interaction (PPI) model is described in detail, highlighting different areas where the cost of IVF can be significantly reduced. They include infrastructure and equipment, personnel, ovarian stimulation protocol (detailed in Chapters II and III) and modification in the laboratory routine regarding oocyte retrieval. CHAPTER V This meta-analysis compared mild ovarian stimulation IVF with conventional treatment in order to counsel patients appropriately. The study showed significantly better outcomes in terms of live birth rates and ongoing pregnancy rates per started cycle, all in favour of conventional stimulation IVF, which therefore currently remains the preferred treatment of choice. CHAPTER VI Understanding the physiology of folliculogenesis has made it possible to integrate mild ovarian stimulation in our unit ART programme at a low cost. (Chapter I) Reassuring clinical outcomes of CC in ART also motivated the unit to maintain low cost of treatment with the use of safe and effective medication. (Chapter II) The finding that prolonged usage of CC does not reduce the risk of premature LH surge has also allowed the unit to maintain the old protocol of 5 days’ use, but motivated us to explore other inexpensive methods. (Chapter III) The PPI model certainly managed to make ART treatment accessible to subfertile couples that would have never had a chance to be proud parents. (Chapter IV) Because this model is feasible and can be implemented at a reasonably low cost, it presents a viable option to make ART accessible in resource-limited countries.
- ItemA critical analysis of preterm birth in a largely homogeneous community near Tygerberg Academic Hospital with a high prevalence of preterm birth(Stellenbosch : Stellenbosch University, 2022-11) Brink, Lucy Theresa; Odendaal, Hendrik Johannes; Hall, David Raymond; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: There is a high priority to address the heavy burden of preterm birth (PTB) on a low- to middle- class community in the Western Cape Province of South Africa (SA), where the Safe Passage Study (SPS) by the PASS Network was conducted. The latter study was undertaken to determine the role of alcohol consumption in stillbirths and sudden infant deaths. We documented a high rate (13.8%) of PTB in that community. Preterm birth (birth before 37 weeks) is one of the most common causes of perinatally related deaths at Tygerberg Academic Hospital (TAH), the tertiary referral hospital for the community. Complications of PTB also account for 75% of perinatal mortalities and more than 50% of chronic infant morbidities and therefore remains one of the greatest challenges in obstetrics. Perinatal outcome is particularly susceptible to socioeconomic conditions that have profound effects on the health of individuals and communities. SA has one of the highest levels of alcohol consumption (including binge drinking i.e. drinking four or more standard drinks during one sitting) as well as concomitant smoking in certain communities. Individuals with low socioeconomic status experience greater exposure to stress and are more likely to engage in risk-taking behaviours such as smoking, drinking and drug use during pregnancy, which may contribute to adverse birth outcomes. Despite the attention given to PTB in medical research, the aetiology remains largely unexplained, and placental pathology may illuminate the clinical understanding thereof. Increasing evidence indicates that placental dysfunction is an important risk factor for PTB, but contexts differ and information from low-income-countries is lacking.
- ItemA critical evaluation of health care reform in maternity services in the Western Cape Province of South Africa, 2007-2012(Stellenbosch : Stellenbosch University, 2016-12) Gebhardt, Gabriel Stephanus; Theron, Gerhardus Barnard; Stellenbosch University. Faculty of Medicine and Health Science. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: This thesis is a critical evaluation of the impact of service delivery shifts within maternity care on the clinical governance of a well-defined geographical service delivery area (Metro East section of the Cape Town health district) during 2007 to 2012. This period saw the implementation of a comprehensive health plan that envisaged the provision of safe maternity care at a non-specialist hospital within the metropolitan area. The data presented in the first part of the thesis shows that well defined levels of maternity care can provide safe management of pregnancies in a large, well-functioning district hospital. A central event in this time period was the opening of a newly-built district hospital in Khayelitsha and the major change in the drainage boundaries of Tygerberg hospital to include referrals from this new hospital. The thesis presents all the clinical governance aspects that went into the planning and eventual execution of a maternity service and the impact it had on the base hospital. The second part investigates the role of the regional maternity service in Tygerberg hospital as it relates to the clinical governance of the regional and district service in the Metro East sub-district. To this extent a few chapters place quality of care aspects such as structural audits, caesarean section rates, maternal and perinatal mortality data, medico-legal liability, patient and provider satisfaction and protocol compliance within this context. An in-depth root-cause analysis was made of all the obstetrics and gynaecology medico-legal cases within the Western Cape which showed that poor clinical note keeping was a major factor hampering defence of cases. The information obtained from this thesis builds on the Western Cape healthcare plan for 2030 aimed at improving quality of care and wellness with an outcomes-based approach and the prioritisation of evidence-based interventions. It concludes with the description of a maternity dashboard for the Tygerberg labour ward and the Metro East maternity service based on the information obtained from this thesis. The tool can inform the hospital management on progress, successes and challenges within the system on a regular basis.
- ItemThe effect of solubilized homologous zona pellucida on the human acrosome reaction, sperm-zona binding and motion characteristics of capacitated human spermatozoa(Stellenbosch : Stellenbosch University, 2003-12) Bastiaan, Hadley Saville; Franken, D. R.; Menkveld, Roelof; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: CHAPTER 1 provides literature based background information to emphasize the use of a sequential, multistep diagnostic schedule for couples in an assisted reproductive program as well as the clinical importance of sperm morphology as recorded by strict criteria during the diagnostic approach of the infertile couple. Furthermore, the chapter includes evidence underlining the growing need for the implementation of the physiologically induced acrosome reaction as an important contribution to the assisted reproductive program. The zona pellucida-induced acrosome reaction (ZIAR), sperm-zona interaction as well as computer-assisted semen analyses were investigated. CHAPTER 2 provides detailed experimental protocols of the materials and methods used in the study. CHAPTERS 3-6 each represent a separate study that was prepared as a scientific paper and encompass the experimental research undertaken in the reproductive biology research laboratory at Tygerberg Hospital to address important aspects of human acrosome processes. In the first study, we aimed to evaluate the regulatory role of the Gi-like protein during the AR of normal sperm donors and the role of intact acrosomes during sperm-zona binding. It seems that pertussis toxin-sensitive Gi-like protein in human spermatozoa plays an important regulatory role in the ZIAR and this underlines the importance of intact acrosomes during sperm-zona binding. In the second study, we aimed to evaluate the relationship between the ZIAR and the percentage normal spermatozoa as well as the sperm-ZP binding potential among men referred for a routine semen analysis. ZIAR testing should become part of the second level of male fertility investigations, i.e., sperm functional testing, since 15% of the andrology referrals revealed an impaired AR response to solubilized ZP. In the third study, we aimed to evaluate the possible relationships between the sperm morphology, the acrosome responsiveness to solubulized human ZP and the sperm-zona binding potential among consecutive andrology referrals and randomly selected IVF cases. ZIAR results provide further information regarding dysfunctional sperm and can be used as an additional diagnostic test since the results predicted fertilization failure during IVF treatment. In the fourth study, we aimed to evaluate changes in the sperm motion characteristics and the occurrence of hyperactivated motility after exposure to ZP among andrology referrals. Solubilized human ZP induces hyperactivated motility among sperm populations that have been capacitated under laboratory conditions. Capacitated spermatozoa have an elevated percentage hyperactivated cells that correlate with the percentage normal spermatozoa in the ejaculate. CHAPTER 7, the general discussion, is brief and concise to avoid unnecessary repetition, underlines the validity of a sequential, multistep diagnostic approach and concludes with the recommendation that the ZIAR should form part of the diagnostic tools in the assisted reproductive program.
- ItemEndocrine function and fertility preservation in women surviving cancer : a study on cancer treatment and fertility(Stellenbosch : University of Stellenbosch, 2010-12) Botha, Matthys Hendrik; Kruger, T. F.; University of Stellenbosch. Faculty of Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: Chapter 1 is a literature review investigating the incidence of cancer in children and young adults. It describes the most important treatment options including chemotherapy, radiotherapy and surgery and the effect of treatment on future endocrine development and fertility. Different primary cancer sites are discussed in more detail. Chapter 2 is a literature review on the effects of cancer surgery in women and the options for fertility sparing. Cervical cancer and pre-cancer are discussed in detail with options for more conservative surgery in selected patients. A summary of the available published cases of trachelectomy with pregnancy outcomes is included. Other gynaecological cancers requiring surgery are also discussed with reference to conservative options. Chapter 3 is a literature review about the medical (pharmacological) options for protection of ovarian function in patients undergoing oncotherapy. The role of gonadotrophin releasing hormone analogues and hormonal contraceptives in ovarian suppression is discussed in detail. Chapter 4 This chapter examines germ cell physiology with reference to cryopreservation. It includes two major parts. Part 1 is the description of germ cell- and follicle physiology, the principles of cryobiology followed by a review of oocyte cryopreservation and ovarian tissue preservation. Both slow freezing and vitrification techniques are described. The second part of chapter 4 is a report on a randomised controlled evaluation of two different slow freezing cryopreservation protocols. This experimental study compared ultrastructural changes in fresh and previously cryopreserved ovarian cortical tissue after equilibration and thawing using two different cryoprotectants. This is the first randomised investigation into DMSO and PROH as cryoprotectants. Chapter 5 is an investigation into cryopreservation of ovarian tissue as a strategy to protect hormonal function and fertility against gonadotoxic treatment. This chapter consists of two parts. The first part is a thorough literature review of all the published work about grafting of previously cryopreserved ovarian tissue. The largest case series found from a single institution was five patients. Another report of six patients included patients from various sites in Denmark. Part 2 is a description of a cohort of patients followed up after re-implantation of previously cryopreserved ovarian cortical tissue. Follow-up hormone levels of 13 individual cases are described in detail. This is the largest case series ever reported. The experimental study described in Chapter 4 and the clinical study described in Chapter 5 was approved by the ethical research committee of the Faculty of Health Sciences, Stellenbosch University, project number N05/10/182. Chapter 6 provides an integrated overview of the incidence and treatment of cancer in young women and how its negative effects may be prevented or mitigated. Aspects of chemotherapy, radiotherapy and surgery are evaluated where it may affect future reproductive health. The role of oocyte and ovarian tissue cryopreservation is discussed. Guidelines are provided for clinicians.
- ItemEstablishing an obstetric critical care unit in a South African tertiary hospital(Stellenbosch : Stellenbosch University, 2016-03) Langenegger, Eduard Jacobus; Hall, D. R.; Mattheyse, F. J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: See full text for summary.
- ItemThe evaluation of different embryo markers and their subsequent effect on embryo development, implantation and pregnancy outcome in an in-vitro fertilization program(Stellenbosch : Stellenbosch University, 2012-12) Kotze, Dirk Jacobus; Kruger, T. F.; Sher, G.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: CHAPTER 1 In this chapter the aim is to outline the different chapters under section A. Against this background, we will conduct a literature review of relevant studies performed, and evaluate their comments regarding identifying embryo markers which can be utilized to improve overall ART outcome. We will evaluate the embryo marker sHLA-G in detail, using a prospective randomized study as well as a retrospective multi-centre study. The role of the morphology and genetic profile of an oocyte, zygote and embryo and subsequent blastocyst formation will be evaluated with the help of WGA/CGH. The work will then be summarized and conclusions will be made as well as possible suggestions for future directions will be indicated. In section B the methodology of the studies explaining the role of the candidate is illustrated. CHAPTER 2 In this chapter the impact of the oocyte/zygote and the embryo on implantation/pregnancy rate was discussed. The morphologic characteristics of the oocyte, the cumulus–oocyte-complex (COC), the zona pellucida, the perivitelline space, cytoplasm and meiotic spindle and the polar body and its appearance were discussed in detail. The morphologic characteristics of embryo fragmentation and its effect on embryo development, ploidy and blastocyst formation were also studied. Embryo markers to predict pregnancy outcome were researched based on the international literature. The pronuclear morphology and early cleavage were highlighted as non-invasive embryo markers to predict outcome. A non-invasive biochemical marker, soluble Human Leucocyte-Antigen-G (sHLA-G), that is expressed by developing embryos was researched. The value of blastocyst transfer and the improved ongoing pregnancy rate compared to cleavage stage embryos were highlighted based on a recent meta-analysis. A detailed discussion on sHLA-G as well as Array-CGH and the future of these tests followed. CHAPTER 3 In this chapter the aim was to compare pregnancy and implantation rates when embryos are selected based on a single Day 3 (D 3) morphology score vs. a GES score plus sHLA-G expression. This was a prospective randomized study (n=214) undergoing fresh ICSI cycles. Embryos were selected for transfer based on either Day 3 morphology score (Group A) or GES-scoring plus sHLA-G expression (Group B). The following results were reported: Clinical [35/107 (33%) vs. 52/107 (49%)] and ongoing pregnancy [20/107 (19%) vs. 52/107 (49%)] rates were significantly different between Group A and Group B (p<0.05). Implantation rates were not significantly different between Group A [52/353 (15%)] and Group B [73/417 (18%)] (p<0.05). The number of pregnancies lost during the first trimester was nearly 12 times higher in Group A [25/52 (48%)]. It was concluded that the miscarriage rate was significantly lower in Group B than Group A and the pregnancy results were superior when embryos were selected based on GES plus sHLA-G expression. CHAPTER 4 Several studies have reported an association between the presence of soluble human leukocyte antigen-G (sHLA-G) in human embryo culture supernatants (ES) with implantation and pregnancy outcome in vitro. However, the actual presence role during implantation and effect on implantation and pregnancy outcome are still controversial. A retrospective multi-centre study was performed on 2040 ICSI patients in six different centers. All embryos were individually cultured and a chemiluminescence enzyme-linked immunosorbent assay (ELISA) was used to detect the presence of sHLA-G in culture medium surrounding embryos. In all centers, a positive sHLA-G result was associated with an increase in odds of multiple clinical implantations (OR: 1.48, 95% CI: 1.07 to 2.05, p-value: 0.0170), and an increased odds of multiple on-going pregnancies (OR: 1.66, 95% CI: 1.10, 2.51, p-value: 0.0170). Data from this multi-centre study emphasize that sHLA-G expression is a valuable non-invasive embryo marker to assist in improving pregnancy outcome with the theoretical potential to reduce multiple pregnancies. A combination of sHLA-G expression and extended embryo culture to the blastocyst stage might provide future tools by which to select single embryos for transfer and reduce the risk of multiple gestational, without compromising their pregnancy rates. CHAPTER 5 In this chapter the ploidy status of first and second polar bodies and Day 3 blastomere, embryo morphology and biochemical (sHLA-G) characteristics were correlated with blastocyst development and subsequent pregnancy outcome. All oocytes/zygotes and embryos were individually cultured to the blastocyst stage. PB-I, PB-II and blastomeres underwent whole genome amplification (WGA) and comparative genome hybridization (CGH) and complete karyotyping. Each embryo‟s culture medium supernatant was collected and analyzed for sHLA-G expression on Day 2. The following results were reported: Fifty seven mature (MII) donor oocytes were obtained, 33/57 (57.9%) were aneuploid, 21/57 (36.8%) were euploid and 3/57 (5%) were “inconclusive”. No correlation was found between CGH status of PB-I, PB-II and the GES-score. Furthermore, no correlation was established between PB-I CGH results and blastocyst morphology grade. There was a significant correlation between PB-I CGH and blastomere CGH results. Euploid and aneuploid PB-I developed into 58% and 67% blastocysts, respectively. Kappa statistics (>0.7) revealed a positive correlation between the ploidy of PB-I, PB-II and the blastomeres. It was concluded that following ICSI and sequential genetic karyotyping of the oocyte/zygote and subsequent blastomeres, the majority of oocytes fertilized and subsequent zygotes developed into blastocysts, despite their ploidy status. We therefore conclude that blastocyst development is not associated with ploidy. CHAPTER 6 Identifying a developmentally competent embryo to transfer that has the highest probability to develop into a live baby has been an issue of debate and continues research. The aim of this chapter is to discuss the morphological, biochemical and genetic features of an embryo that has been shown to be predictive of implantation and pregnancy outcome in ART using most current evidence. A literature search was performed looking at the correlation between pronuclear morphology, early cleavage, cleavage stage embryos, blastocyst development, the presence of sHLA-G, CGH, embryo development and implantation/pregnancy rates in ART. Based on the available literature, a combination of observations could assist the scientist with embryo selection. The pronuclear stage morphology, the early embryo division, cleavage embryo stage and quality of the day 3 embryos provides limited guidance. However, choosing a blastocyst with a positive sHLA-G result on Day 5 is the optimal combination to make the final selection before embryo transfer or freezing. This non-invasive approach should improve pregnancy outcome and reduce multiple pregnancy rates. As far as the use of the more invasive technology such as aCGH is concerned, more research on pregnancy outcome is needed. CHAPTER 7 A combination of observations for embryo selection, starting with oocyte grading, pronuclear stage morphology, early zygote cleaving and cleavage-stage embryo morphology/quality on Day-3, however, ultimately using extended embryo culture and choosing a blastocyst on Day 5 with positive sHLA-G values available, will assist the scientist in making the final decision before selecting an embryo for transfer or cryopreservation. The use of aCGH (for chromosomal analysis) is invasive and is still considered experimental. Finally we conclude that despite all the above mentioned parameters to select an embryo for transfer that will develop into a live baby, more extensive research and international corroboration is needed in order to improve and standardize embryo selection criteria.
- ItemEvaluation of gamete dysfunction as a cause of failed human in vitro fertilization(Stellenbosch : Stellenbosch University, 2000-12) Esterhuizen, Aletta Dorothea; Franken, D. R.; Stellenbosch University. Faculty of Medicine & Health Sciences. Dept. of Medicine.ENGLISH ABSTRACT: Chapter 1 provides literature based background information on the clinical importance of sperm morphology as recorded by strict criteria during the diagnostic approach of the infertile couple. Furthermore, the use of a sequential diagnostic schedule for couples in an assisted reproductive programme is emphasized. The author revisited the literature on chromatin packaging of spermatozoa and addresses this issue as an additional semen parameter providing information relating to DNA damaged spermatozoa. The chapter also includes evidence underlining the growing need for the implementation of the acrosome reaction as an important contribution to the assisted reproductive programme. Chapter 2 provides detailed descriptions of the material and methods used during the study. Chapter 3 is sub-divided into 5 sections, each of which represents a separate study that was prepared as a scientific paper. The study included 338 couples consulting for infertility treatment at various gynaecologists in Pretoria and Johannesburg. The diagnostic assisted reproductive laboratory support was provided by the Andrology laboratory of Drs du Buisson and partners from Pretoria. In the first study the role of chromatin packaging as an indicator of in vitro fertilization rates, the semen samples from 72 men were used to record their chromatin packaging quality as well as their sperm morphology classification. Significant different percentages CMA3staining (mean±SE) were recorded among the 2 morphology groups, namely 65.9%±3.5 and 44.5%±1.7 (p=0.001). Using cut off values for chromatin packaging established during the first study, the second study utilized semen from 140 men in the in vitro fertilization (IVF) and intracytoplasmic sperm injection programme (ICSI) to analyze for sperm concentration, motility, morphology and chromatin packaging (CMA3).IVF and ICSI data were stratified using 3 basic cut off values for CMA3staining, namely <44%, >44-60% and >60%. The study concluded that results on the chromatin packaging quality of spermatozoa could be used as an additional parameter of sperm quality since it could provide valuable information on decondensation status of a given sperm population. The third study aimed to establish zona pellucida induced acrosome reaction response (ZIAR) among 35 couples with normal and G-pattern sperm morphology and repeated poor fertilization results during assisted reproduction treatment. Interactive dot diagrams, divided patients into 2 groups i.e. ZIAR<15% and ZIAR>15% with mean fertilization rates of 49% and 79%, respectively. The study concluded that the ZIAR test has diagnostic potential, since it can assist the clinician to identify couples that will benefit from ICSI therapy. The forth study revisited the importance of micro-assay for acrosome reaction determinations in a diagnostic andrology laboratory. The micro-assay not only allows the use of a single zona pellucida, but also facilitates the future possibility of using recombinant zona pellucida proteins in a diagnostic test system. The final study in Chapter 3 includes results obtained from 49 couples (172 oocytes) and aimed to evaluate the role of chromatin packaging and sperm morphology during sperm-zona binding, sperm decondensation and the presence of polar bodies among 170 oocytes that failed in vitro fertilization (IVF). Odds ratio analyses indicated that being in the a group with elevated CMA3 staining i.e. >60%, the risk of decondensation failure increases 15.6 fold relative to normal CMA3 staining <44%. Chapter 4 underlines the validity of the sequential diagnostic approach and summarizes the results and value of a multistep diagnostic scheme. The chapter concludes with the recommendation that both chromatin packaging quality and zona pellucida mediation of the acrosome reaction should be part of the diagnostic tools in the assisted reproductive programme.
- ItemHuman gamete micromanipulation and intracytoplasmic sperm injection (ICI) : its impact on severe male infertility(Stellenbosch : Stellenbosch University, 2000-12) Windt, Marie-Lena; Kruger, T. F.; Stellenbosch University. Faculty of Medicine & Health Sciences. Dept. of Obstetrics & Gynaecology.ENGLISH ABSTRACT: Intracytoplasmic sperm injection (ICSI) introduced a revolutionary way of treatment for male factor infertility. With the exception of some cases of non-obstructive azoospermia, all other male factor infertility cases have the potential to be successfully treated with ICS!. The only prerequisite seems to be the presence of a motile or viable immotile sperm cell for each oocyte. In this study we report on our own experience with the development and implementation of the ICSI method in the Reproductive Biology Unit at Tygerberg Hospita!. An analysis of 5 years of ICSI experience showed that semen parameters, sperm morphology, motility and concentration did not influence fertilization and pregnancy rates adversely. In most cases, patients who could not be treated with in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT), due to poor semen parameters or fertilization failure, were treated successfully with ICS!. Even a case of globozoospermia was treated successfully with ICS!. Testicular spermatozoa, fresh or frozen-thawed, also resulted in excellent fertilization and pregnancy rates. Cryopreservation of testicular samples facilitated the management of the infertile couple, aiding the coordination of the recovery of vital gametes from both partners and also limiting the repetition of testicular biopsies. Incubation (maturation) of testicular spermatozoa also induced an enhancement in pregnancy rates. It can be concluded that ICSI proved to be a treatment method with success similar to that of in vitro fertilization (IVF) and gamete intrafallopian transfer (GIFT), in spite of a severe male factor. The study also indicated transfer route and embryo quality (viability) to be very important factors in the success of ICS!. The tubal transfer route was shown to be a significant contributor to the pregnancy success (compared to uterine transfer) as was the transfer of embryos that showed early division to the 2-cell stage, 26 hours post injection. The transfer of early dividing embryos into the fallopian tube resulted in a pregnancy rate of almost 40%, a result similar to that of GIFT with a mild male factor. The role of the oocyte in fertilization and pregnancy success was also revealed indirectly by the introduction of ICS!. Visual observation of denuded oocytes was possible and many morphological features, normal and abnormal, can be observed. Immature oocytes can also be identified and it was shown that they could be successfully matured in vitro before injection. In this study transmission electron microscopy (TEM) was used to study abnormalities in oocyte morphology. The standard method was adapted and modified for single cell TEM. The abnormalities observed included lysosomal and non-lysosomal degeneration (yellowish or darkly coloured oocytes), degeneration and vacuole formation (vacuolated oocytes), large secondary lysosomes filled with multiple small lipid droplets - lipofuscin body (refractile body) and a fragmented oocyte. It was also possible to study at ultrastructural level, possible reasons for fertilization failure in ICS!. Different stages of oocyte activation failure, cytoplasmic immaturity, sperm cell extrusion, abnormal sperm cell decondensation, female spindle abnormalities and technique related factors were observed. TEM was also successfully implemented to elucidate the reason for infertility in a patient with a longstanding, unexplained history of infertility. TEM evaluation of two of the patient's unfertilized oocytes revealed a spindle abnormality with contributing cytoskeletal anomalies at ultrastructural level. The modified TEM technique offers a valuable tool to study this small, but important group of patients with unexplained infertility. ThisTEM study opened up a new, valuable and interesting avenue of research with both diagnostic and prognostic value for patients with unexplained infertility. ICSI is therefore a valuable method in the treatment of especially male factor infertility. It is the most advanced fertilization technique developed in the last decade in this field. Not only can almost all male factor patients be treated, but unexplained female infertility can also be exposed, studied and hopefully in future also be treated with micromanipulation methods.
- ItemThe impact of HIV status on staging, treatment and outcomes in locally advanced cervical carcinoma(Stellenbosch : Stellenbosch University, 2019-12) Simonds, Hannah; Botha, Matthys Hendrik; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: Cervical carcinoma is one of the most frequently diagnosed malignancies in women in many countries in sub-Saharan Africa, including South Africa. In sub-Saharan Africa, among women without HIV the age-standardised cervical cancer incidence rate is greater than 40 per 100 000. However, women infected with both the human-immunodeficiency virus (HIV) and the human papilloma virus (HPV) have a higher risk of developing cervical carcinoma than women infected with HPV alone. Published studies of the ideal staging methods, treatment algorithms, and outcomes for women with comorbid locally advanced cervical carcinoma and HIV are scarce. The aim of this body of work is to fill some of these gaps. We conducted four cohort studies of patients with locally advanced cervical carcinoma with or without HIV, recording demographic data, staging information and treatment delivered. Additional information gathered for individual studies included treatment response and survival outcomes. We evaluated the statistical significance of differences between HIV-positive and negative patients. Logistic regression models were utilised to evaluate risk for toxicity, treatment response, and survival outcomes. In the first of three retrospective cohort studies, among 383 patients, early response to chemoradiation was found to be related to advanced stage [OR 2.39, 95% CI 1.45-3.96] and completion of brachytherapy [OR 3.14; 95% CI 1.24-7.94] but not HIV status. In the second retrospective study, among 213 patients undergoing radical radiotherapy, acute Grade 3 / 4 toxicity was associated with receiving chemotherapy [OR4.41; 95%CI 1.76- 11.1; p 0.023] and having HIV [OR 2.16; 95% CI0.98-4.8; p 0.05]. In a prospective study of 492 patients, OS at 5 years was 49.5% (95%CI; 44.6% - 54.4%) among HIV-negative patients but only 35.9% (95% CI; 23.9% - 48.0%) among HIV-positive patients (p=0.002). In our Cox models, factors affecting outcome were HIV infection, stage IIIB disease, hydronephrosis, and delivery of concurrent chemotherapy. In the fourth cohort study, among 273 patients with locally advanced cervical carcinoma who underwent a radiotherapy planning PET-CT scan, overall 235 (84.5%) were upstaged. Upstaging was not associated with HIV status (HIV-negative 83.9% vs HIV-positive 87.2%; p=0.47). Following the PET-CT scan, among the 263 patients who attended for radiotherapy treatment, intent changed for 124 patients (46.3%): 53.6% of HIV-positive patients and 42.9% of HIV-negative patients (p=0.11). This body of work demonstrated that in HIV-positive patients, integration of PET-CT into staging algorithms for cervical carcinoma is a viable option. During treatment HIV-positive patients experienced increased toxicity, but most were able to complete treatment, and their 5-year overall survival was nearly 40%. Among women with locally advanced cervical cancer, those with HIV infection should be treated with the best standard of care. Future research should focus on factors that improve outcomes for these women.
- ItemThe interaction between human spermatozoa and its homologous zona pellucida : scientific advances and clinical significance(Stellenbosch : Stellenbosch University, 2002-12) Oehninger, Sergio C.; Franken, D. R.; Stellenbosch University. Faculty of Medicine & Health Sciences . Dept. of Obstetrics & Gynaecology.ENGLISH ABSTRACT: Infertility is a very common problem worldwide. Recent data have shown that disorders of the male represent the most common single defined cause of infertility. This proposal examines the clinical significance and fundamental physiological aspects of human gamete interaction. These studies are focused on the assessment of the cellular-molecular mechanisms involved in human sperm binding to its homologous zona pellucida resulting in the physiologic induction of the acrosome reaction. We have developed and validated in vitro bioassays that assess specific steps of the fertilization process that are critical for early embryo development. The results of our translational research have already had a significant impact on the overall evaluation of male infertility and on the clinical management of the infertile man in the assisted reproduction arena. Furthermore, the unveiling of the basic mechanisms involved in human gamete interaction will ultimately allow for both (i) the development of new male reproductive diagnostic capabilities and (ii) the design of improved and safer therapies aiding conception in childless couples suffering from male infertility.
- ItemMaternal deaths, near misses and great saves. Severe maternal outcome in Metro East, Western Cape Province, South Africa(Stellenbosch : Stellenbosch University, 2023-12) Heitkamp, Anke; Theron, Gerhardus Barnard; De Vries, Johanna Inge Petra; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. Obstetrics and Gynecology.ENGLISH ABSTRACT: Objective To assess the incidence of Severe Maternal Outcome (SMO), comprising maternal mortality (MM) and near miss (MNM), in Metro East healthdistrict, Western Cape Province, South Africa between November 2014 and November 2015 and identify associated determinants leading to SMO with the aim to improve maternity care. Methods Design: Region wide population-based case control study. Women were included in the study, if they were maternal deaths or met MNM criteria, both as defined by World Health Organization. Characteristics of women with SMO were compared with a sample of women without SMO, matched for age and parity, taken from midwifery-led obstetric units from two residential areas in Metro East, using multivariate regression analysis. Results Incidence of SMO was 9.1 per 1000 livebirths, of MNM 8.6 per 1000 live births. Main causes of SMO were obstetric hemorrhage and hypertensive disorders. Factors associated with SMO were HIV (adjusted odds ratio (aOR) 24.8; 95% confidence interval (95% CI) 10.0 – 61.6), preeclampsia (aOR 17.5; 95% CI 7.9-38.7), birth by caesarean section (aOR 8.4; 95% CI 5.8-12.3) and chronic hypertension (aOR 2.4; 95% CI 1.1 – 5.1). Conclusion Evaluation of SMO incidence and associated determinants supports optimizing tailored guidelines in Metro-East health district to improve maternal health.
- ItemMolecular-genetic investigation into host susceptibility and variability to HIV/AIDS in the South African population(Stellenbosch : Stellenbosch University, 2003-12) Pretorius, Gideon Stephan; Kotze, Maritha J.; De Jong, Geertje; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology .ENGLISH ABSTRACT: The risk of human immunodeficiency virus type-1 (HIV-1) infection and rate of progression towards development of the acquired immunodeficiency syndrome (AIDS) is determined by a combination of viral characteristics, immune function and host genetic variation. Although mutations of the chemokine and chemokine co-receptor genes and allelic variation of the major histocompatibility complex (MHC) have been studied extensively, variation in these host genetic factors does not explain the differences in HIV/AIDS susceptibility in all cases. This study represents the first analysis of new candidate genes implicated in iron metabolism and immune function in relation to HIV-1 disease in the African context. Both case-control association studies and genotype-phenotype correlations were performed to determine the potential functional significance of genetic variants that may be involved, either directly or indirectly, in susceptibility to HIV-1 disease in the South African population. Genotyping was performed to identify potentially important polymorphisms in the solute carrier family 11 member 1 (SLC11A 1), haemochromatosis (HFE) and protein-tyrosine phosphatase receptor-type C (PTPRC/CD45) genes in HIV-seropositive versus HIVseronegative individuals. This was followed by HLA-B27 genotyping in HIV-1 infected individuals with known disease status to determine the potential impact of combined genotypes for different mutations identified in the same study cohort. Preferential association with any of the mutations screened for in the CCR5, SLC 11A1, HFE or CD45 genes were not detected in HLA-B27 positive individuals identified. These findings were in accordance with the independent protective role of HLA-B27 in relation to disease progression in HIV-1 infected individuals. Although differences in allelic distribution were not significant between the study groups, an apparently African-specific mutation 32A~G, identified in an exonic splicing silencer element (ESS-1) of the CD45 gene, appeared to predominate in HIV-1 infected subjects with WHO Class I disease status and slow progression to AIDS. This mutation was present in 35.7% (5/14) of HIV-seropositive individuals with WHO Class I disease status, whilst absent in 22 HIV-seropositive patients with rapid disease progression. This finding may be related to differences in proportions of both CD4+ and CD8+ subsets observed following flow cytometry (FACs) analys.s in two HIV-seropositive individuals with mutation 32A~G, compared with an HIV-seropositive individual without this mutation. Analysis of the iron-related SLC11A1 and HFE genes did not reveal significant associations with modified risk of HIV-1 infection or progression to AIDS in our predominantly African study population. However, the effect of the virus on iron metabolism was demonstrated for the first time at the DNA level. Haemoglobin levels were significantly reduced in both HIV-seropositive (P=O.004) and HIV-seronegative (P=O.02) Black Africans with mutation IVS3-48c~g in the HFE gene, compared with mutationnegative individuals in both groups. Since this effect was more pronounced in HIV-infected individuals compared with controls, presence of the HFE mutation seems to result in an even stronger effect on haemoglobin levels, which may be related to the acute phase response following virus infection. This effect possibly results from genetic variation in a nearby gene involved in innate immunity, most likely in the HLA region on chromosome 6. It therefore seems possible that genetic variation in any of the host molecules involved in response to infection could contribute to clinical outcome. The significance of the multitude of host genetic factors investigated in this study, or previously implicated in susceptibility to HIV-1 infection and disease progression, revealed a complex interrelationship between the host and HIV-1. In some instances the disease process following HIV-1 infection depends on combined effects of different mutations occurring in the same individual, while independent effects of specific genes in conjunction with environmental influences may explain diverse clinical outcomes in others.
- ItemThe Preeclampsia intervention with Esomeprazole (PIE) trial: A double blind, randomised, placebo-controlled trial to treat early onset severe preeclampsia(Stellenbosch : Stellenbosch University, 2019-04) Cluver, Catherine Anne; Theron, Gerhardus Barnard; Walker, Susan; Tong, Stephen; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: This body of work addresses the clinical dilemma posed by preterm preeclampsia. Firstly, we tested a potential therapeutic (esomeprazole) for the treatment of early preterm preeclampsia in a double-blind randomised controlled trial. The primary outcome of interest was prolongation of gestation, with secondary outcomes including maternal and perinatal outcomes. Importantly, this study was underpinned by extensive pharmacokinetic and biomarker studies on both plasma samples and placental tissue. We found that a daily dose of 40mg of esomeprazole did not prolong pregnancy in early preterm preeclampsia and there were no differences in maternal or neonatal outcomes or markers of endothelial dysfunction. The esomeprazole concentrations that were observed in our participants were within the lower range of concentrations used in our preclinical in vitro studies. We therefore concluded that 40 mg may not have been sufficient to have efficacy in treating preterm preeclampsia, and future studies should consider the role of a higher dose or intravenous administration, which has a higher exposure over time and peak concentration. Secondly, we assessed the impact of coexisting fetal growth restriction on pregnancy latency, obstetric, maternal and perinatal outcomes among women undergoing expectant management of early preterm preeclampsia. We found that the latency-to-delivery interval was significantly shorter among pregnancies with coexisting fetal growth restriction. These pregnancies were less likely to reach 34 weeks gestation and more likely to be delivered for suspected fetal compromise. More women with coexisting fetal growth restriction underwent an emergency caesarean section without a trial of labour induction and of those considered eligible for induction of labour, the rate of emergency caesarean section was higher among those with fetal growth restriction. Postnatally, the presence of coexisting fetal growth restriction was associated with a higher rate of postnatal death and necrotising enterocolitis. Interestingly, the rate of maternal complications did not differ between the groups. We concluded that coexisting fetal growth restriction, diagnosed at the same time as preeclampsia, is an important determinant of pregnancy outcome among women being managed expectantly for early preterm preeclampsia Thirdly, we sought to determine the role of expectant management of preeclampsia and the hypertensive disorders of pregnancy after 34 weeks gestation by assimilating the available data in a Cochrane systematic meta-analysis. Based on the limited data available, maternal outcomes appear better with planned early delivery for hypertensive disorders after 34 weeks’ gestation, but it is unclear whether this is associated with increased risks for the baby, especially at earlier gestations. It was not possible to determine whether planned early delivery was beneficial for different hypertensive conditions, particularly preeclampsia. We concluded that further studies are needed, preferably with reliable characterisation of hypertensive disease sub-types, to determine the ideal timing of delivery to optimise maternal and perinatal outcomes for hypertensive disorders of pregnancy occurring after 34 weeks gestation. This research provides new information about a candidate therapeutic for the treatment of preeclampsia. Clinical aspects of the hypertensive disorders of pregnancy that could further improve management are also discussed.
- ItemThe role of sperm morphology in assisted reproduction (ART)(Stellenbosch : Stellenbosch University, 2012-12) Kruger, Theunis Frans; Theron, Gerhard; Henkel, Ralf; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.Please refer to full text for abstract.
- ItemSperm DNA fragmentation : implications in assisted reproductive technologies(Stellenbosch : Stellenbosch University, 2007-12) Hoogendijk, Christiaan F. (Christiaan Frederik); Kruger, T. F.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Obstetrics and Gynaecology.ENGLISH ABSTRACT: Male fertility has for many years been defined in vitro as the ability of sperm to fertilize oocytes and to obtain early cleavage-stage embryos. Spermatozoa comprise of an extraordinary high percentage of polyunsaturated fatty acids in their plasma membrane. Due to an extremely low content of cytoplasm, sperm cells have a particularly low potential to scavenge reactive oxygen species (ROS), and are therefore highly sensitive to oxidative processes, which lead to sperm nucleus DNA damage/fragmentation. Normally, DNA fragmentation occurs in every ejaculate and can be induced by an excessive ROS production of active leukocytes or the spermatozoa themselves. Under distressed conditions, DNA fragmentation may also occur in the testis as a result of oxidative processes in the apoptotic cascade. These DNA fragmentations can be regarded as late signs of programmed cell death (apoptosis). Clinically, DNA fragmentation in spermatozoa results in significantly decreased implantation and pregnancy rates especially in patients with oligo- and/or teratozoospermia. The p-pattern normal sperm morphology has been shown to give poorer fertilization rates in vitro than the g- and n-patterns. In this study there is reported on the significant correlation found between the p-pattern normal sperm morphology and sperm DNA fragmentation as measured with the terminal deoxynucleotidyl transferase-mediated dUDP-biotin end labeling (TUNEL) assay. This finding further explains the lower fertility potential of patients presenting with p-pattern normal sperm morphology. In addition, this study explores the intricate relations between ROS in the semen, DNA fragmentation of the spermatozoa, as measured with the TUNEL assay and the sperm chromatin structure assay (SCSA ), spermatozoa apoptotic status and sperm parameters as measured with a standard semen analysis. Positive correlations were found between ROS and the apoptotic status of the sperm, as well as between sperm with non-fragmented DNA and sperm concentration and percentage motility. The results emphasize the importance of sperm selection especially when the treatment of choice is intracytoplasmic sperm injection (ICSI). An early sign of programmed cell death, also known as apoptosis, is the externalization of phosphatidylserine (PS) from the inner membrane leaflet to the outer leaflet. PS shows a high affinity to Annexin V. Apoptotic spermatozoa are able to fertilize oocytes, but embryo senescence may occur at the time when the paternal genes are activated. In this study there is reported on a novel method whereby spermatozoa can be separated on the basis of their apoptotic status through flow cytometry. Results showed that the normal sperm morphology, according to strict criteria, of the resultant nonapoptotic sperm fraction is significantly higher than that of the apoptotic counterpart. With refinement of this technique, it will be possible in future to use these separated non-apoptotic sperm cells during ICSI for fertilization. From the above it is apparent that the spermatozoon has to play a vital role in the development of the embryo from fertilization to implantation and pregnancy. It is, however, important to note that besides the gametes, there are other critical factors which contribute to a successful in vitro fertilization (IVF) cycle, among these are the in vitro culture conditions. In this regard, this study compared two sequential embryo culture systems. It was found that the more complex medium resulted in better day three embryo quality and a better blastocyst formation rate and pregnancy rate. These findings highlight the importance of a holistic perspective towards the complexity of the factors involved in affecting embryo quality and pregnancy outcome.
- ItemA study of different clinical and biochemical parameters in polycystic ovary syndrome affecting ovulation induction outcome and fertility potential(Stellenbosch : Stellenbosch University, 2008-12) Siebert, T. I.; Kruger, T. F.; Stellenbosch University. Faculty of Health Sciences. Dept. of Obstetrics and Gynaecology.Chapter 1 presents a literature study on the diagnostic debate of PCOS. The literature study includes a discussion of the recent Rotterdam consensus statement regarding the diagnosis of PCOS. This is followed by a discussion on the essential work-up of the patient presenting with PCOS. Finally, chapter 1 presents a discussion on the complexity of the different variations in women presenting with PCOS. Chapter 2 is a literature review on ovulation induction methods in patients who present with PCOS. This literature study puts special emphasis on the different available methods used for ovulation induction in women with PCOS and the profounding effect weight loss will have in managing these patients. This chapter also addresses the use of newer agents, like aromatase inhibitors (Letrozole), and the current role of each of these agents in ovulation induction protocols. Chapter 3 is a literature overview on the effect of Metformin in Clomiphene-resistant PCOS women. The inclusion criteria of this review was all prospective randomized trials where Metformin was added for ovulation in the Clomiphene-resistant PCOS patient. The data is presented as a metaanalysis. Chapter 4 is a prospective randomise control trial to evaluate the benefit of metformin if added to Clomiphene in a primary ovulation induction protocol in comparison to Clomiphene alone. This chapter also evaluates all factors influencing ovulation outcome. Finally in the discussion section all the recent studies published addressing this topic were reviewed. Chapter 5 is a literature review to evaluate the classification systems for semen parameters and the in vivo fertility potential. This data is also used to establish fertility/subfertility thresholds for semen parameters. This chapter also presents the results of a prospective and retrospective study of the semen analysis of the partners of women with PCOS. We believe that this population presents the best reference group to study the semen profile of the general male population. Chapter 6 is a summary of the results of these studies and serves as an evidence based approach for ovulation induction in women with PCOS.