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۱۸۴ مطلب در اسفند ۱۳۹۲ ثبت شده است

What is terminological and lexical consistency?

Terminological consistency means consistent use of terms within a text and across relevant texts. For example, term pin can mean штифт, палец, булавку, шплинт and a lot more. Some of these translations are interchangeable because the same part can be correctly called both штифтом и палец и шплинт. However, in technical text this translation should be selected once and forever (e.g. штифт) and use it through the text, otherwises the reader will be confused what object was meant.
There are often a few translators working on a text and each of them can translate a term correctly but different. In the space industry term feathering (rotation of a solar array) is correctly called флюгирование. Engineers, however more often use term “разворот” (a turn). Regardless of what option is selected it should be the same through the text.
But this is not all. Projects may contain many documents where same objects are mentioned. Naturally, one should seek consistency of terms in all such documents.
Lexical consistency is the same as the terminological one, only it deals not with special terms, but ordinary lexical units. For examples, last names or titles of publications can be translated differently (Вильям или Уильям), but should be the same as in all occurences in the documents.
Language Interface Inc. takes special measures to ensure terminological and lexical consistency. To achieve that a number of methods of software and organizational nature is used.


http://webda.ajums.ac.ir/rha/index.php?q=mataleb/1531/%D8%A2%D9%86%DA%86%D9%87-%D8%AE%D8%A7%D9%86%D9%85-%D9%87%D8%A7-%D8%A8%D8%A7%DB%8C%D8%AF-%D8%AF%D8%B1%D8%A8%D8%A7%D8%B1%D9%87-%DB%8C-%D9%85%D8%B1%D8%A7%D9%82%D8%A8%D8%AA-%D9%BE%DB%8C%D8%B4-%D8%A7%D8%B2-%D8%A8%D8%A7%D8%B1%D8%AF%D8%A7%D8%B1%DB%8C-%D8%A8%D8%AF%D8%A7%D9%86%D9%86%D8%AF&printable=1



 مقالات 

بررسی روش‌های درمانی بیماران PCO با نازایی مقاوم به کلومیفن
دکتر حاجیه‌السادات اسماعیل‌لو،*1 دکتر نوش‌آفرین ستاری،2 دکتر لیلی صفدریان3   ۱۳۹۱/۰۵/۰۱ دریافت فایل

زمینه و هدف: اختلال تخمک‌گذاری یکی از علل شایع نازایی زنان می‌باشد و اکثر آنان مبتلا به سندرم تخمدان پلی‌کیستیک (PCO) می‌باشند. اولین قدم در درمان نازایی این افراد، تحریک تخمک‌گذاری با کلومیفن سیترات است. 1/22-20% موارد بیماران به تحریک تخمک‌گذاری با کلومیفن مقاوم می‌باشند. در این مطالعه مروری درمان‌های مختلف در بیماران PCO مقاوم به درمان کلومیفن و میزان اثربخشی هر کدام بررسی شده است. روش بررسی: اطلاعات موجود در منابع علمی و مقالات مرتبط شامل Medline Cochrane, و EBSCO و SCOPUS و غیره مورد بررسی قرار گرفت. یافته‌ها: 235 مقاله یافت شد که اغلب مطالعات RCT در مقایسه درمان‌های مختلف موارد مقاوم به درمان کلومیفن بود. همه مقالات کلومیفن و کاهش وزن را خط اول درمان در درمان بیماران PCO دانسته‌اند. استفاده از متفورمین و سایر حساس‌کننده‌های انسولین در اغلب موارد در ترکیب با کلومیفن موثر بودند. قدم بعد درمان با گنادوتروپین‌ها یا Laparascopic Ovarian Drilling (LOD) است که اثر بخشی یکسان دارند. ولی به علت هزینه کمتر LOD ارجح‌تر بوده است. اخیرا تمایل به استفاده از لتروزول به علت عوارض کمتر و کارایی مشابه کلومیفن بالا رفته است. درمان‌هایی مانند گلوکو-کورتیکوئیدها، تاموکسیفن، نالترکسان، بروموکریپتین وUltrasound-guided Transvaginal ovarian Drilling (UTND) نیز موثر گزارش شده‌اند. نتیجه‌گیری: جمع‌بندی مطالعات تمایل به استفاده از روش‌های با تهاجم و عوارض کمتر را نشان داد و تمایل بیمار برای زمان حامله شدن در انتخاب درمان مهم است.

Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4

زمینه و هدف


سندرم تخمدان پلی‌کیستیک یک اختلال اندوکرین هتروژن است که یک نفر از هر 15 زن (تقریبا 10-5% جمعیت زنان) را در دنیا مبتلا می‌کند. اختلال اساسی که در این سندرم مشاهده می‌گردد، افزایش ترشح یا فعالیت هورمون‌های آندروژنی و در بسیاری از بیماران فعالیت غیرطبیعی هورمون انسولین است. علت این سندرم ناشناخته است ولی مطالعات علمی زمینه ژنتیک را که تحت تاثیر محیط دوران بارداری، سبک زندگی و یا هر دو است را مسئول می‌دانند. اغلب خانم‌های نازا با این اختلال عدم تخمک‌گذاری مزمن، در پاسخ به کلومیفن قادر به تخمک‌گذاری هستند.2 با این حال، تا 30% بیماران بدون تخمک‌گذاری باقی می‌مانند. علاوه بر آن از 70% بیماران که در پاسخ به کلومیفن تخمک‌گذاری کرده‌اند 50% باردار می‌شوند.4و3 کلومیفن سیترات دارویی است که به‌طور گسترده توسط ژنیکولوژیست‌ها نسخه می‌شود. مصرف آن در دوزهای استاندارد باعث میزان اوولاسیون و باروری 80% و 50-40% می‌شود.5FDA مصرف کلومیفن را در دوزهای 100-50 میلی‌گرم روزانه برای پنج روز در هر سیکل تایید کرده است. در زنانی که به‌دنبال مصرف کلومیفن تخمک‌گذاری می‌کنند ولی باردار نمی‌شوند، شکست کلومیفن سیترات نباید قلمداد شود. در یک مطالعه 88% زنان با تخمک‌گذاری بدون عامل نازایی مشخص باردار می‌شوند در حالی که فقط 8% از آنها که همراهی با یک فاکتور نازایی دارند بادار می‌شوند. این مشاهدات اهمیت ارزیابی فاکتورهای نازایی را قبل از تغییر به سایر درمان‌ها را در زنانی که تخمک‌گذاری می‌کنند ولی باردار نمی‌شوند نشان می‌دهند.6 راهنمای مورد توافق فعلی توصیه می‌کند که خانم‌هایی که با کلومیفن باردار نمی‌شوند بایستی با تزریق گنادوتروپین‌ها یا جراحی لاپاراسکوپیک تخمدان‌ها جهت کاهش ترشح آندروژن‌ها درمان شوند. اگر پس از سه سیکل درمان با کلومیفن بارداری اتفاق نیافتد بایستی بررسی علل نازایی انجام شود. اگر سطح FSH بالاست، ذخیره اووسیت تخمدانی ممکن است کم باشد و مصرف کلومیفن موثر نیست. سن خانم نیز در قدرت باروری مهم است. زنان بالای 37 سال کمترین قدرت باروری را دارند، بنابراین IVF-ET و یا سایر روش‌های کمک باروری باید مدنظر باشد.8

تقسیم‌بندی WHO در عدم تخمک‌گذاری: WHO زنان بدون تخمک‌گذاری را بر اساس سطح گنادوتروپین به سه گروه تقسیم می‌کند. (گروه I،گروه II،گروه III)

گروه I شامل زنان با سطح گنادوتروپین آندوژن پایین و تولید استروژن آندوژن بسیار پایین می‌باشند. این زنان تمایل به خونریزی رحمی به دنبال Progestin challenge test ندارند و هیچگاه در پاسخ به درمان کلومیفن تخمک‌گذاری نمی‌کنند. آنها ممکن است به درمان GNRH پالسی یا تزریق گنادوتروپین پاسخ دهند. برخی زنان در WHO گروه I لاغر هستند (BMI زیر 20)؛ وزن‌گیری در این گروه ممکن است با تخمک‌گذاری خودبه‌خودی یا بهبودی در پاسخ به عوامل تحریک تخمک‌گذاری همراه باشد.9

گروه III اشاره به عدم تخمک‌گذاری همراه با هایپرگنادوتروپیک هایپواستروژنمیا دارد و 30-10% علل عدم

 تخمک‌گذاری را شامل می‌شود. علل اولیهPOF  یا مقاومت تخمدانی (فولیکولر) است. این زنان ممکن است به درمان گنادوتروپین، IVF-ET یا تخمک اهدایی نیاز داشته باشند، آنها هیچگاه به درمان‌های تحریک تخمک‌گذاری پاسخ نمی‌دهند.

گروه II: استراتژی درمانی در WHO گروه II، در دو گروه I و III مفید نیستند. این گروه زنان تا حدودی سطح گنادوتروپین نرمال داشته و شواهد واضح تولید استروژن آندوژن را دارند و به‌دنبال progestin challenge test خونریزی رحمی دارند. علت شایع در این گروه PCO می‌باشد. کرایتریاهای این سندرم اختلالات تخمک‌گذاری، هایپرآندروژنیسم (با علایم بالینی آکنه و هیرسوتیسم و علایم آزمایشگاهی تستوسترون یا DHEA-S بالا)، تخمدان پلی‌کیستیک در سونوگرافی، ورد سایر بیماری‌ها است.8 زنان PCO که مقاومت به انسولین شدید10 و سطح بسیار بالایی از تستوسترون دارند کمترین پاسخ به کلومیفن را دارند. مداخلات اختصاصی، مانند کاهش وزن می‌تواند پاسخ به کلومیفن را بهبود بخشد. درمان با گلوکوکورتیکوئیدمی تواند سطح DHEA-S و درمان قبلی با OCP سطح تستوسترون را می‌تواند کاهش دهد.11 این مداخلات پاسخ تخمک‌گذاری به کلومیفن را بهبود می‌دهند.

کاهش وزن: اغلب زنان pcos با نازایی BMI بالای Kg/m227 دارند. مطالعات Case series زیادی گزارش کرده‌اند که کاهش وزن می‌تواند باعث بهبود تخمک‌گذاری در این زنان شود. به عنوان مثال، یک مطالعه اثرات کاهش وزن را در 20 زن با BMI متوسط kg/m232، آمنوره برای بیش از سه ماه و افزایش غیر طبیعی سطح آندروستن دیون، تستوسترون و یا دی‌هیدرواپی آندروسترون ارزیابی کرده است.12 مداخلات رژیمی که شامل محدودیت کالری تا Kcal/day1500-1000 و کاهش وزن kg7/9 (kg2/15-8/4) (kg2/15-8/4) بوده کاهش واضحی در سطح تستوسترون و غلظت انسولین را به همراه داشته است. اغلب این زنان تخمک‌گذاری کرده‌اند (8/20) و برخی حاملگی خودبه‌خود داشته‌اند (4/20). نتایج مشابهی در سایر مطالعات منتشر شده است.15-13

رژیم تعدیل شده: کلومیفن با دوز بالا (mg/d250-200) برای 10-8 روز در زنانی که به دوزهای استاندارد مقاوم هستند ممکن است استفاده شود. این درمان در زنانی که گنادوتروپین خارجی نمی‌توانند مصرف کنند مناسب است ولی بیشتر از دوزی که FDA توصیه کرده استفاده می‌شود.16

درمان ترکیبی با Insulin sensitizers: اغلب زنان PCO با نازایی مقاومت به انسولین دارند. اغلب زنان با BMI بالای 27 یا آکانتوزیس نیگریکانس مقاومت به انسولین دارند.18و17 (ترشح بالای انسولین ممکن است مستقیما ترشح آندروژن تخمدانی را تحریک کند19 و در عوض کاهش تولید انسولین ممکن است ترشح آندروژن تخمدانی را کم کرده و میزان تخمک‌گذاری را افزایش دهد.

متفورمین- برخی مطالعات RCT نشان داده‌اند که ترکیب متفورمین و کلومیفن در تحریک تخمک‌گذاری در زنان PCO که قبلا در درمان با کلومیفن به تنهایی با شکست مواجه شده‌اند موثر است. اگرچه متفورمین ممکن است در تخمک‌گذاری موثر باشد در مطالعه مروری قبلی سال 1387 در بررسی درمان بیماران PCO نازا با متفورمین، تجویز متفورمین در بیماران با عدم تحمل به گلوکز و مقاومت به انسولین توصیه شده و درباره سن، وجود یا عدم وجود چاقی مرکزی اتفاق نظر وجود نداشت و استفاده از انتخاب متفورمین یا کلومیفن بر مبنای تمایل بیمار برای زمان حامله شدن می‌باشد، در صورتی که بیمار تمایل به بارداری سریع باشد، کلومیفن و در غیر این صورت متفورمین ارجح است. جمع‌بندی نتایج در بیماران PCO نازای بدون تخمک‌گذاری نشان نداد که افزودن متفورمین به کلومیفن باعث افزایش میزان حاملگی و یا تولد زنده شود.20 در یک مطالعه RCT روی 225 زن PCO به نظر می‌رسد که متفورمین در بیماران PCO در دو زیر گروه سن بالا و با چاقی مرکزی موثر باشد. در مطالعه Palomba میزان تخمک‌گذاری تجمعی در دو گروه کلومیفن و متفورمین مشابه بود در حالی که میزان حاملگی در گروه متفورمین بالاتر و میزان سقط کمتر بوده است.21 در مطالعه Legro استفاده از کلومیفن به متفورمین ارجح بوده و میزان تخمک‌گذاری تجمعی و حاملگی و تولد زنده بیشتر بود.28 در مطالعه Zain میزان تخمک‌گذاری در گروه کلومیفن بالاتر از متفورمین بوده اما در میزان حاملگی و تولد زنده تفاوت آماری دیده نشد.22 اساس بیانیه صادر شده اجماع سال 2008 در تسالونیکی یونان که استفاده از متفورمین در بیماران PCO را به بیماران با عدم تحمل گلوکز محدود می‌کند، دو RCT انجام شده توسط Moll و Legro بود که نشان می‌داد اضافه کردن متفورمین به کلومیفن میزان تولد زنده را افزایش نمی‌دهد.23 راهکرد مورد توافق در حال حاضر توصیه می‌کند زنانی که با کلومیفن باردار نشدند بایستی با تزریق گنادوتروپین یا جراحی لاپاراسکوپیک تخمدان درمان شوند. این باعث می‌شود که متفورمین در زنان PCO نازا با مقاومت به انسولین که به دقت انتخاب شده‌اند و به درمان‌های استاندارد مثل کاهش وزن و کلومیفن پاسخ نداده‌اند ولی خواهان اجتناب از عوارض جدی درمان‌های تهاجمی هستند استفاده شود.24 Sigrun در سال 2009 نشان داده که درمان متفورمین در جریان سیکل IVF، بیشترین اثر را روی DHEAS داشته ولی اثر ریباند در قطع درمان متفورمین دیده شده است. به طوری‌که در عرض 36 ساعت پس از قطع درمان مجددا سطح آندروستندیون و تستوسترون آزادافزایش یافته و DHEAS کاهش می‌یابد.25

تیازولیدیندیون‌ها: دو داروی دیگر که توسط FDA جهت دیابت تایید شده‌اند، روزیگلیتازون و پیوگلیتازون هستند. اثرات این داروها به طور گسترده روی القا تخمک‌گذاری در زنان PCO شناخته نشده است. به هر حال استفاده از این داروها تا اطمینان از اثرات کاردیوواسکولر توصیه نمی‌شود.26 مطالعه Brettenthaler روی 40 زن PCO که تحت درمان با پیوگلیتازون (mg/d30) به مدت سه ماه قرار گرفتند، کاهش ترشح انسولین، افزایش سطح SHBG و در نتیجه کاهش واضح سطح آندروژن آزاد در مقایسه با گروه کنترل داشتند و در نهایت افزایش میزان تخمک‌گذاری (02/0p<) داشتند.27

مهارکننده‌های آلفا گلوکوزیداز: آکاربوز، یک مهارکننده آلفا گلوکوزیداز که در درمان دیابت تیپ 2 استفاده می‌شود، روی بیماران مقاوم به کلومیفن در حال مطالعه است. در مطالعه‌ای روی 30 زن PCO مقاوم به کلومیفن، در گروه اول کلومیفن با متفورمین و در گروه دوم کلومیفن و آکاربوز داده شده بود. در هر دو گروه نسبت LH/FSH و سطح تستوتسترون کاهش واضحی داشته و میزان تخمک‌گذاری و باروری افزایش بارزی داشت تخمک‌گذاری در ماه دوم با متفورمین بیشتر بود. ولی کاهش وزن و BMI فقط در گروهی که آکاربوز گرفته بودند مشخص بود.28 مطالعه مروری Kircher در سال 2008 نیز بهبودی سیکل قاعدگی، هیرسوتیسم، آکنه، مارکرهای کاردیوواسکولرو کاهش وزن را در زنان PCO مقاوم به کلومیفن نشان داده است.29

درمان ترکیبی با گلوکوکورتیکوئید: در زنان PCO گروه II DHEA-S بالاتر از دو میزان حاملگی و تخمک‌گذاری را در  کسانی که کلومیفن دریافت می‌کنند کاهش می‌دهد. برخی مطالعات نشان داده‌اند که درمان با کلومیفن و گلوکوکورتیکوئید میزان حاملگی را در این زنان بهبود می‌بخشد. پردنیزولون (mg/d5) نیز استفاده شده است.30 درمان با دگزامتازون کوتاه‌مدت در فاز فولیکولر، فولیکوژنز را تسهیل کرده و اثرات کلومیفن را در القای تخمک‌گذاری تقویت می‌کند. در یک مطالعه، 64 زن نازا بدون تخمک‌گذاری به طور تصادفی تحت درمان باmg50 کلومیفن روز 9-5 سیکل و دگزامتازون  (mg/d5/0) قرار گرفتند در صورت عدم پاسخ دوز کلومیفن به 100 و سپس 150 افزایش یافت. میزان تخمک‌گذاری و حاملگی واضحا در مقایسه با گروهی که فقط کلومیفن دریافت کرده بودند افزایش یافت. (تخمک‌گذاری: 13/13 در مقابل 6/12، حاملگی: 11/13 در مقابل 4/12).26 در مطالعه دیگر روی 230 خانم PCO مقاوم به کلومیفن با سطح DHEA-S نرمال به طور تصادفی کلومیفن روز 9-5 سیکل (mg/d200) با و بدون دگزامتازون (mg/d2) روز 9-5 سیکل، میزان بارداری 41 در مقابل چهار درصد بود.31 درمان ترکیبی با گلوکوکورتیکوئید ممکن است بدون توجه به سطح DHEA-S به‌صورت تجربی داده شود.32-30 اگر تخمک‌گذاری اتفاق افتاد، درمان سه تا شش سیکل ادامه می‌یابد. در صورتی که حاملگی رخ دهد و یا تخمک‌گذاری اتفاق نیافتد دگزامتازون باید قطع شود. دکتر پارسانژاد در سال 2002 نشان داده است، اضافه کردن دگزامتازون در زنان PCO مقاوم به کلومیفن با DHEA-S نرمال، باعث افزایش میزان تخمک‌گذاری (88% در مقابل 20%) و میزان حاملگی (40% در مقابل 2/4) می‌شود.33Aboubakr Elnashar در مطالعه‌اش در سال 2006 به نتایج مشابهی، میزان تخمک‌گذاری (75%در مقابل 15%) و میزان حاملگی (40% در مقابل 5%) دست یافته است.34

بروموکریپتین: این دارو جهت تحریک تخمک‌گذاری در زنانی که گالاکتوره یا هایپرپرولاکتینمی دارند کاربرد دارند. همچنین این دارو در زنان با پرولاکتین نرمال یا بدون گالاکتوره که شکست درمان با کلومیفن داشته‌اند نیز امتحان شده است ولی شواهد کافی برای آن وجود ندارد.26

نالترکسان: اپیوئیدهای داخلی می‌توانند باعث اختلالات مختلف متابولیک و باروری در زنان PCO شوند. مطالعه‌ای در سال 2008 روی 30 زن PCO نشان داده که دادن نالترکسان در همراهی با کلومیفن کاهش واضح BMI، انسولین ناشتا، LH، نسبت LH/FSH و افزایش میزان بارداری را به دنبال داشته است.35

 

Aromatase inhibitors: در یک مطالعه بزرگ RCT آینده‌نگر در سال 2009، بررسی روی 1387 زن PCO مقاوم به کلومیفن انجام شده و بیماران به سه گروه تقسیم شدند: گروه اول لتروزول، گروه دوم کلومیفن و دو دوز r FSH و گروه سوم r FSH مداوم تا روز تزریق HCG دریافت کرده بودند در نتایج مطالعه، حاملگی در گروه اول به طور واضح بالاتر بود که می‌توان نتیجه گرفت میزان حاملگی و تخمک‌گذاری با لتروزول از کلومیفن بهتر است. در گروه دوم کنسل شدن سیکل از دو گروه دیگر بیشتر بود. در این مطالعه بر اساس سطح استرادیول سرم نتیجه‌گیری شده که در سطوح استرادیول زیر 30، r FSH مداوم و در سطوح 60-30، r FSH به تنهایی یا با کلومیفن و در سطوح بالاتر از 60 لتروزول بهترین پروتکل درمانی می‌باشد. میزان سقط در سه گروه تفاوت واضحی نداشت.36 یک مطالعه RCT در سال 2008 روی 140 مورد PCO اثرات درمانی لتروزول را با کلومیفن به همراه گنادوتروپین مقایسه کرده است تعداد فولیکول بالغ و سطح استرادیول سرم در روز تزریق HCG در گروه لتروزول پایین‌تر بود در حالی‌که ضخامت آندومتر در گروه کلومیفن به طور واضح پایین‌تر بود. حاملگی در گروه لتروزول بالاتر بود. حاملگی چندقلویی در گروه لتروزول نسبت به کلومیفن و گنادوتروپین پایین‌تر بود. در مطالعه دیگر در سال 2009، در مقایسه اثر کلومیفن و لتروزول در 64 مورد PCO، میزان فولیکول بالغ در هر دو دارو تفاوتی نداشت ولی بزرگترین قطر فولیکول بالغ، تعداد فولیکول‌های بالاتر از 14، ضخامت آندومتر، سطوح LH در لتروزول به طور مشخصی بالاتر از کلومیفن است. در گروه کلومیفن میزان استرادیول بالاتر بوده است.37 در مطالعه Badawy در سال2009 در مقایسه اثر لتروزول با متفورمین به همراه کلومیفن در زنان PCO مقاوم به کلومیفن، تفاوتی در میزان بارداری دیده نشده است.38 در مطالعه H. fouad میزان تخمک‌گذاری با لتروزول 6/54% و میزان باروری 25% برآورد شده و افراد پاسخ‌دهنده به لتروزول و افراد مقاوم به آن، تفاوتی در سن، طول مدت نازایی، BMI، دور کمر، LH، FSH و نسبت LH/FSH نداشتند.39 در مطالعه Badawy در مقایسه اثر لتروزول و آناستروزول در زنان PCO مقاوم به کلومیفن، میزان تخمک‌گذاری و بارداری تفاوت معنی‌دار آماری نداشتند.40

درمان هورمونی: در یک pilot study در سال 2005، در گروه اول (34n=) کلومیفن به همراه استرادیول خوراکی در روز هشت سیکل (mg/bid5/1) و ژل واژینال پروژسترون بعد از LH surge به مدت دو هفته و گروه دوم فقط کلومیفن دریافت کرده‌اند. 74% از گروه اول و 79%از گروه دوم تخمک‌‌گذاری کردند که از بین آنها 17%از گروه اول و 7% از گروه دوم باردار شده‌اند. این مطالعه اثرات حمایتی قوی کلومیفن در همراهی با استرادیول خوراکی و ژل پروژسترون واژینال را در افزایش میزان بارداری در مقایسه با مصرف کلومیفن تنها نشان می‌دهد.41 یک مطالعه کوهورت در سال 2009 اثرات درمان قبلی با DHEA را در زنان مقاوم به کلومیفن و کاندید IUI بررسی کرده است. در 47 مورد DHEA خوراکی (mg/d75) به مدت 60 روز قبل از COS (با کلومیفن یا لتروزول یا FSH)در IUI داده شده بود. در این گروه فولیکول‌های آنترال در روز سوم سیکل، تعداد فولیکول‌های غالب، سطح استرادیول در روز مصرف HCG و ضخامت آندومتر به طور مشخصی بالاتر بود. ولی میزان نیاز به FSH در این گروه بیشتر بود. میزان حاملگی به طور قابل ملاحظه‌ای در مصرف DHEA (14/47 در مقابل 4/46) بیشتر بود.42

گنادوتروپین‌ها: در زنان مقاوم به کلومیفن یا کلومیفن در ترکیب با متفورمین، قدم بعدی درمان با گنادوتروپین است. در حالی که این درمان چند مشکل اساسی دارد: مشکل بودن تیتراژ دوز آن در جهت تخمک‌گذاری مونوفولیکولر، شیوع بالای چندقلویی در 30%یا بیشتر موارد، ریسک OHSSبالا، بالا بودن شیوع سقط خودبه‌خودی با این درمان نسبت به موارد حاملگی خودبه‌خود. مشکل اصلی در درمان زنان PCO با گنادوتروپین‌ها، حساسیت زیاد آنها به FSH می‌باشد که با پروتکل (COS) Controlled Ovarian Stimulation قابل کنترل است. درمان با دوز پایین FSH (IU75) شروع شده و به‌تدریج اضافه می‌شود (نه بیشتر از IU/d75) و یا با دوز بالا شروع شده و با دیدن فولیکول با سایز بالا دوز آن را کم می‌کنند. با این درمان تا 70% سیکل Uniovulatory و میزان بارداری تا 20% و چندقلویی 6% گزارش شده است.43 در مطالعات اخیر، استفاده همزمان از متفورمین در درمان با FSH یا IVF، افزایش میزان باروری و کاهش OHSS را به همراه داشته است. درمان با GnRH آنالوگ‌ها قبل از FSH/HMG میزان بارداری را افزایش و باعث کاهش سقط خودبه‌خودی در زنان PCO گروه II WHO می‌شود.44 در مقایسه تاثیر درمانی urinary FSH در مقابل hMG در زنان PCO مقاوم به کلومیفن توسط Vandekerckhove P، تفاوتی در میزان باروری در دو گروه دیده نشد. ولی درمان با FSH میزان OHSS متوسط تا شدید را کاهش می‌دهد.

 

تاموکسیفن: اخیرا درمان با تاموکسیفن به همراه کلومیفن در درمان زنان PCO مقاوم به کلومیفن مطرح شده است. مطالعه Zakherah و همکارانش در سال 2010، روی 150 خانم PCO مقاوم به کلومیفن انجام شده است که گروه اول با تاموکسیفن و کلومیفن و گروه دوم با drilling لاپاراسکوپیک درمان شده‌اند. تفاوتی در میزان تخمک‌گذاری، بارداری و تولد زنده در دو گروه دیده نشد. با این حال در گروه اول ضخامت آندومتر در روز تزریق hCG بالاتر بود.45

درمان جراحی: درمان جراحی در القا تخمک‌گذاری در PCO به سال 1930 بر می‌گردد.

Wedge resection تخمدانی: خط اول درمان در بیماران نازا با عدم تخمک‌گذاری در زمینه PCO درمان دارویی می‌باشد. درمان جراحی سنتی در PCO،Wedge resection  تخمدانی است. روشی که در آن حدود 1/3 تخمدان را با لاپاراتومی خارج می‌کنند. در مطالعات اولیه روی 108 بیمار که Wedge resection تخمدانی دوطرفه شده‌اند، در 95 بیمار سیکل نرمال قاعدگی بازگشته و میزان حاملگی 85% بود.46 مطالعات بعدی مزایای این روش را با درصد موفقیت متغیر تائید کرده‌اند. با این حال روشن است که رزکسیون تخمدانی با ایجاد چسبندگی‌های اطراف آدنکس‌ها همراه است که مزایای این روش را زیر سئوال می‌برد.47 رزکسیون تخمدانی از طریق لاپاراسکوپی هم انجام می‌گیرد که چسبندگی کمتری را در مقایسه با لاپاراتومی ایجاد می‌کند.50-48

Laparoscopic ovarian drilling: این روش تعدیل شده روش رزکسیون تخمدانی می‌باشد. حفرات متعدد در سطح تخمدان با استفاده از لیزر یا الکتروکوتر ایجاد می‌شود که باعث کاهش سطح آندروژن و بازگشت تخمک‌گذاری سیکلیک می‌شود. این روش با میزان تخمک‌گذاری در حد 80% و میزان حاملگی بعد 12 و 18 و 24 ماه به‌ترتیب 68-54 و 73-62 و 82-68 درصد همراهی دارد. با این حال اثرات طولانی مدت شناسایی نشده است. بنابراین درمان جراحی در PCO در زنان با این کرایتریاها توصیه می‌شود: 1- شکست تخمک‌گذاری علی‌رغم درمان با کلومیفن و متفورمین، 2- وزن نرمال، چون این روش در زنان چاق (BMI بالای 30) ناموفق است،3- سطح LH بالا (بیشتر از 10).روش‌های متعدد درمان لاپاراسکوپیک شامل الکتروکوتر (دیاترمی)، Laser drilling و بیوپسی‌های متعدد وجود دارد.51

شواهدی مبنی بر اینکه کدام روش ارجح است وجود ندارد با این حال درمان با لیزر drilling در حال حاضر به علت آسیب حرارتی محیطی و نکروز کمتر در استرومای تخمدان متداول‌تر است. روش شایع در حال حاضر استفاده از الکترود سوزنی unipolar است که در هر تخمدان  6-4 سوراخ ایجاد می‌شود. باید توجه داشت که هر چه آسیب حرارتی کمتر باشد، چسبندگی بعدی کمتر خواهد بود. در 15 خانمی که تحت بررسی ثانویه لاپاراسکوپیک قرار گرفتند، 11 زن بدون چسبندگی و چهار زن چسبندگی خفیف فقط در سطح تخمدان داشتند.52 در یک مطالعه RCT شامل 72 خانم PCO با عدم تخمک‌گذاری به‌طور تصادفی تحت درمان با Laparascopic ovarian diathermy (LOD) و Clomiphene Citrate (CC) قرار گرفتند. در صورت عدم پاسخ به CC بیمار تحت درمان LOD و در عدم پاسخ به LOD با CC درمان شدند. در نتیجه در گروه CC، 44% و در گروه LOD، 27% حاملگی رخ داده است که تفاوت معنی‌دار آماری نداشته است. بعد از درمان ثانویه میزان بارداری بالاتر بوده ولی مختصر افزایش می‌یابد. در نتیجهLOD ، هیچ ارجحیتی به CC در خط اول درمان PCO ندارد.53 در یک مطالعه روی 32 زن PCO که مقاومت به کلومیفن داشته‌اند و بر اساس سطح آندروژن به دو گروه آندروژن بالا و آندروژن پایین تقسیم شدند و تحت درمان LOD قرار گرفتند در نتیجه تخمک‌گذاری و میزان حاملگی بعد از LOD در دو گروه تفاوت مشخصی نداشت.54 یک مطالعه بزرگ RCT نشان داده که میزان موفقیت دیاترمی تخمدانی (الکتروکوتر) در مقایسه با گنادوتروپین‌ها یکسان بوده ولی چندقلویی در آن کمتر بوده است.55 مطالعه Mohiuddin در سال 2007 در استرالیا، با پی‌گیری طولانی مدت زنان PCO مقاوم به کلومیفن نشان داد، میزان بارداری به دنبال LOD، 79% بود.56 تغییرات آندوکرینی به دنبال جراحی لاپاراسکوپیک، کاهش موقت آندروستندیون و کاهش طولانی‌تر سطح LH, Testosteron و Inhibin و بر عکس افزایش FSH می‌باشد که در جهت اصلاح اختلالات آندوکرینی PCO است.57 در یک مطالعه روی 17 زن PCO غلظت آندروژن سرم به دنبال کوتر لاپاراسکوپیک تخمدان‌ها کاهش یافته بدون اینکه تغییری در حساسیت به انسولین یا سطح لیپوپروتیین‌ها ایجاد شود.58 برعکس در مطالعه دیگر روی 12 زن PCO مقاومت به انسولین بعد آن کاهش یافته است.59

در یک مطالعه روی 200 زن PCO که با LOD درمان شده بودند، تقریبا همه مدت طولانی پس از جراحی پریود منظم داشتند، ولی اثرات طولانی‌مدت آن بررسی نشده، بنابراین درمان لاپاراسکوپیک فقط در موارد خواهان حاملگی توصیه می‌شود.60 در مطالعه قبلی سال 2008، 52 زن PCO نازا که مقاوم به کلومیفن بودند (گروه 1) را با 46 زن با سیکل قاعدگی نرمال به عنوان گروه کنترل (گروه 2) از نظر پروفایل هورمونی و تغییرات جریان خون داپلر در استرومای تخمدانی قبل و بعد از LOE (الکتروکوتر لاپاراسکوپیک تخمدانی) مقایسه کردند. اندکس‌های داپلر (Pulsatility index and Resistance index) به‌طور واضح در گروه یک قبل از LOE پایین‌تر بود.

در گروه یک بعد از LOE سطح تستوسترون و LH به‌طور واضح کاهش (05/0p<) و اندکس‌های داپلر جریان خون استرومای تخمدانی به طور واضح افزایش یافت (کاهش velocity) که می‌توانند مطرح‌کننده کاهش میزان OHSS در زنان PCO بعد از LOE باشد. در حال حاضر LOE به عنوان درمان ترجیحی خط اول در درمان زنان PCO مقاوم به کلومیفن پذیرفته شده است.61

در مطالعه H.Y Malkawi که روی 63 زن PCO مقاوم به کلومیفن انجام شده تفاوتی در نتایج کاهش سطح آندروژن و سیکل قاعدگی و میزان باروری در ایجاد پنج و یا 10 پانکچر در drilling laparoscopic ovarian دیده نشده است.62Palomba و همکارانش در مطالعه‌ای تفاوتی در میزان تخمک‌گذاری و حاملگی و تولد زنده با مصرف متفورمین و یا LOD در زنان PCO مقاوم به کلومیفن نداشتند.63

مطالعه Van Wel در مقایسه اثر LED با القا تخمک‌گذاری با recombinant FSH در زنان PCO مقاوم به کلومیفن، میزان بارداری در هر دو گروه 67% بوده ولی به علت هزینه کمتر LED و چندقلویی کمتر، درمان با LED را ارجح دانسته است.64

مطالعات 2009 در مقایسه درمان با متفورمین و LED در زنان PCO مقاوم به کلومیفن نشان داده است درمان با متفورمین مقاومت به انسولین را بیشتر کاهش داده است ولی در LED، سیکل قاعدگی منظم بیشتر (2/58% vs 4/76%)، میزان تخمک‌گذاری بیشتر (5/33% vs 8/50%) و میزان بارداری بیشتر (20% vs 2/38%) گزارش شده است.65

 

Ultrasound-guided Transvaginal ovarian Drilling (UTND)

یک درمان آلترناتیو برای لاپاراسکوپی می‌باشد. در مطالعه‌ای روی 163 زن PCO مقاوم به کلومیفن که درمان UNTD با LOD مقایسه شده است، زمان انجام UNTD متوسط 3/15 دقیقه بوده که در مقایسه با LOD (6/25 دقیقه) تفاوت قابل ملاحظه‌ای داشت. در دو گروه تفاوتی در میزان بهبودی هیرسوتیسم، آکنه، سیکل قاعدگی نرمال و میزان حاملگی وجود نداشت. این مطالعه، درمان UNTD را به عنوان جایگزین خط اول درمانی، با هزینه کمتر و به صورت سرپایی برای بیماران PCO مقاوم به کلومیفن مطرح کرده است.66

نتیجه‌گیری: در بیماران PCO، کلومیفن و کاهش       وزن خط اول درمان بوده و استفاده از متفورمین و سایر حساس‌کننده‌های انسولین در اغلب موارد در ترکیب با کلومیفن موثر بودند. قدم بعد درمان در بیماران مقاوم به کلومیفن، گنادوتروپین‌ها یاLaparascopic Ovarian Drilling (LOD)  است که اثربخشی یکسان دارند. ولی به علت          هزینه کمتر LOD ارجح‌تر بوده است. اخیرا تمایل به استفاده از لتروزول به علت عوارض کمتر و کارایی مشابه کلومیفن          بالا رفته است. درمان‌هایی مانند گلوکوکورتیکوئیدها، تاموکسیفن، نالترکسان، بروموکریپتین و (Ultrasound-guided Transvaginal ovarian drilling (UTND) نیز موثر گزارش شده‌اند.


 



Abstract:

 

Treatment of clomiphene-resistant women with polycystic ovary syndrome

Esmaillou HS. MD,* Sattari N. MD,** Safdarian L. MD.***

Introduction & Objective: Several approaches have been proposed to induce ovulation in women with PCOS. At the present, clomiphene citrate (CC) administration is considered the first choice treatment in PCOS women, whereas no clear data are in the literature regarding the management of CC-resistant women with PCOS. However, 20%–22.1% of PCOS women fail to ovulate with incremental doses of CC.

Materials and methods: In this review article ,The electronic search strategy involved conducting a literature search for all pertinent published RCTs and articles on the treatment of cc-resistant women with PCOS using the Cochrane central and the bibliographic databases Medline, Ebsco, Scopus, etc.

Results: 235 articles that met the inclusion criteria were identified that most of them were RCT. In most articles Clomiphene citrate and weight loss are the first line infertility treatment for women with PCO. Some randomized clinical trials have shown that the combination of metforminand other insulin sensitizers plus clomiphene is effective for inducing ovulation in women with PCOS who have previously failed to conceive with clomiphene therapy alone. next step is treatment with gonadotropin injections or laparascopic ovarian drilling (LOD). gonadotropins were as effective as laparoscopic ovarian drilling in promoting ovulation and pregnancy but LOD because of its low cost prefer. Adjunctive glucocorticoid, Bromocriptine , nalteroxane treatment and Ultrasound-guided Trans vaginal ovarian Drilling (UTND) may also be effective.

Conclusions: However, a patient's values and preferences should play an important role in determining treatment options. Therefore, for patients who place a high value on avoiding the higher multiple gestation rate and the risk of ovarian hyperstimulation associated with gonadotropin therapy, or potential surgical complications with laparoscopic surgery, it is reasonable to offer additional attempts at ovulation induction with combination medical therapy (eg. metformin or dexamethasone).

Keywords: Clomiphene citrate, polycystic ovary syndrome, infertility, clomiphene resistant

*Resident of Obstetrician and Gynecology, TUMS, Shariati Hospital.

**Resident of Obstetrician and Gynecology, TUMS, Shariati Hospital.

***Specialist of Obstetrician and Gynecology, TUMS, Shariati Hospital.


 


References:

 


1. A. Mahdavi, L.Safdaria.Iranian J. of gynec. & obstet. 1387,3(4),64-67.

2. Amer, SA, Li, TC, Metwally, M, et al. Randomized controlled trial comparing laparoscopic ovarian diathermy with clomiphene citrate as a first-line method of ovulation induction in women with polycystic ovary syndrome. Hum Reprod 2009; 24:219.

3. Garcia, J, Jones, GS, Wentz, AC. The use of clomiphene citrate. Fertil Steril 1977; 28:707.

4. Nunley, WC, Bateman, BG, Kitchen, JD. Reproductive performance of patients treated with clomiphene citrate. South Med J 1985; 78:31.

5. Adashi, EY. Clomiphene citrate initiated ovulation. Semin Reprod Endocrinol 1986; 4:255.

6. Gysler, M, March, CM, Mishell, DR, Bailey, EJ. A decade's experience with an individualized clomiphene treatment regimen including its effect on the postcoital test. Fertil Steril 1982 37:161.

7. Wang, CF, Gemzell, C. The use of human gonadotropins for the induction of ovulation in women with polycystic ovarian disease. Fertil Steril 1980; 33:479.

8. Up to date,ver 17.3, Strategies for improving the efficacy of clomiphene induction of ovulation

9. Bates, GW, Bates, SR, Whitworth, NS. Reproductive failure in women who practice weight control. Fertil Steril 1982; 37:373.

10.    Murakawa, H, Hasegawa, I, Kurabayashi, T, Tanaka, K. Polycystic ovary syndrome. Insulin resistance and ovulatory responses to clomiphene citrate. J Reprod Med 1999; 44:23.

11.    Daly, DC, Walters, CA, Soto-Albors, CE, et al. A randomized study of dexamethasone in ovulation induction with clomiphene citrate. Fertil Steril 1984; 41:844.

12.    Pasquali, R, Antenucci, D, Casimirri, F, et al. Clinical and hormonal characteristics of obese and amenorrheic women before and after weight loss. J Clin Endocrinol Metab 1989; 68:173.

13.    Bates, GW, Whitworth, NS. Effect of body weight reduction on plasma androgens in obese, infertile women. Fertil Steril 1982; 38:406.

14.    Guzick, DS, Wing, R, Smith, D, et al. Endocrine consequences of weight loss in obese, hyperandrogenic, anovulatory women. Fertil Steril 1994; 61:598.

15.    Huber-Buchholz, MM, Carey, DGP, Norman, RJ. Restoration of reproductive potential by lifestyle modification in obese polycystic ovary syndrome: role of insulin sensitivity and luteinizing hormone. J Clin Endocrinol Metab 1999; 84:1470.

16.    Badawy A; Allam A; Abulatta M.Reprod Biomed Online] 2008 Jun; Vol. 16 (6), pp. 825-9.

17.    Administration Barbieri, RL. Induction of ovulation in infertile women with hyperandrogenism and insulin resistance. Am J Obstet Gynecol 2000; 183:1412.

18.    Barbieri, RL, Ryan, KJ. Hyperandrogenism, insulin resistance and acanthosis nigricans syndrome: a common endocrinopathy with distinct pathophysiologic features. Am J Obstet Gynecol 1983; 147:90.

19.    Barbieri, RL, Makris, A, Randall, RW, et al. Insulin stimulates androgen accumulation in incubations of ovarian stroma obtained from women with hyperandrogenism. J Clin Endocrinol Metab 1986; 62:904.

20.    Akbarian MD.,L-Safdarian,Iranian J.of gynec. & obstet.,1387,3(4),52-63

21.    Moll e,corevaar JC,Bossuyt PM,Van der veen F.Hum Reorod . 2008 ; 23(8): 1830-4

22.    Palomba S,orio F JR,Russo T,TolinoA,Zullo F.J Clin Endocrinol Metab. 2007 ; 92(9):3498-503

23.    Legro RS,Barnhart HX,Schlaff WD,Carr BR,Dimond MP,Carson SA.N Engl J Med. 2007 ;356(6):551-66

24.    Zain M,Jammaluddin R,Ibrahim A,Norman RJ.Fertil Steril.2008 Mar  3

25.    Akbarian MD.,L-Safdarian,Iranian J.of gynec. & obstet.,1387,3(4),52-63

26.    Up to date,ver17.3,ovulation induction with clomiphene .

27.    Sigrun B. Kjøtrød M.D, Arne Sunde Ph.D, Vidar von Düring M.D. and Sven M. Carlsen M.D., Ph.D. Fertility and Sterility
Volume 91, Issue 2, February 2009, Pages 500-508

28.    Up to date,ver17.3,ovulation induction with clomiphene .

29.    Nora Brettenthaler, Christian De Geyter, Peter R. Huber, And Ulrich Keller .J Clin Endocrinol Metab 89: 3835–3840, 2004

30.    A.So¨nmez, L.Yas, K.Savan, S.Koc, J.O zcan, A.Toklar, F.Yazıcıog˘lu, A.Akgu¨n    and N.Sut.Human Reproduction Vol.20, No.1 pp. 175–179, 2005

31.    Kircher C; Smith KP. Ann Pharmacother.2008 Jun; Vol. 42 (6), pp. 847-51.

32.    Isaacs, JD Jr, Lincoln, SR, Cowan, BD. Extended clomiphene citrate (CC) and prednisone for the treatment of chronic anovulation resistant to CC alone. Fertil Steril 1997; 67:641.

33.    Parsanezhad, ME, Alborzi, S, Motazedian, S, Omrani, G. Use of dexamethasone and clomiphene citrate in the treatment of clomiphene citrate-resistant patients with polycystic ovary syndrome and normal dehydroepiandrosterone sulfate levels: a prospective, double-blind, placebo-controlled trial. Fertil Steril 2002; 78:1001.

34.    Use of clomiphene citrate in women. Fertil Steril 2003; 80:1302.

35.    M. Parsanezhad, Saaid Alborzi M.D.Fertility and Sterility Volume 78, Issue 5, November 2002, Pages 1001-1004

36.    Aboubakr Elnashar1, Emad Abdelmageed, Mahmod Fayed and Magdy Sharaf. Human Reproduction Vol.21, No.7 pp. 1805–1808, 2006

37.    Ahmed MI; Duleba AJ; El Shahat O; Ibrahim ME; Salem A .Hum Reprod.2008 Nov; Vol. 23 (11), pp. 2564-9

38.    J. ASIST.REPORTED(2009) 26: 19-24

39.    Arch.gyn.obstet.(2009) 280-201-205

40.    Hatem Abu Hashim M.D., M.R.C.O.G, Tarek Shokeir M.D. and Ahmed Badawy M.D., Ph.D. Fertility and Sterility. Departments of Obstetrics & Gynecology, Mansoura University, Mansoura, EgyptReceived 23 May 2009;  accepted 14 July 2009. 

41.    Aboubakr Elnashar M.D, Hany Fouad M.D., Magy Eldosoky M.D. and Naser Saeid M.Sc. Fertility and SterilityVolume 85, Issue 2, February 2006, Pages 511-513

42.    Badawy A; Mosbah A; Shady M.Fertility And Sterility [Fertil Steril] 2008 May; Vol. 89 (5), pp. 1209-12.

43.    Elkind-Hirsch, Karen E; Darensbourg, Carmen; Creasy, George;  Gipe, Dan  Current Medical Research and Opinion, Volume 21, Number 7, July 2005 , pp. 1035-1040(6)

44.    M. A. Bedaiwy, E. Ryan, O. Shaaban, S. Blanco Mejiya,E. A. Classens , R. F.Casper. P-537  Wednesday, October 21, 2009

45.    Zakherah MS; Nasr A; El Saman AM; Shaaban OM; Shahin AY.Int J Gynaecol Obstet] 2010 Mar; Vol. 108 (3), pp. 240-3.

46.    Wang, CF, Gemzell, C. The use of human gonadotropins for the induction of ovulation in women with polycystic ovarian disease. Fertil Steril 1980; 33:479.

47.    Hughes E, Collins J, Vandekerckhove P. Cochrane Database Syst Rev.1996 Apr 22;(1)

48.    Stein IF, Sr. Duration of fertility following ovarian wedge resectionstein-leventhal syndrome. West J Surg Obstet Gynecol 1964; 72:237.

49.    Pirwany, I, Tulandi, T. Laparoscopic treatment of polycystic ovaries. Is it time to relinquish the procedure?. Fertil Steril 2003; 80:241.

50.    Portuondo, JA,Melchor, JC, Neyro, JL, Alegre, A. Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy. Endoscopy 1984; 16:143.

51.    Luciano, AA. Laparotomy versus laparoscopy. Prog Clin Biol Res 1990; 358:35.

52.    Luciano, AA, Maier, DB, Koch, et al. A comparative study of postoperative adhesions fallowing laser surgery by laparoscopy versus laparotomy in the rabbit model. Obstet Gynecol 1989; 74:220.

53.    Hum Reprod. 2009 Jan;24(1):219-25. Epub 2008 Sep 14.

54.    J.OBSTET.GYN.RES.VOL 33.NO.2:174-130-APRIL 2007

55.    Cochrane Database of Systematic Reviews (COCHRANE DATABASE SYST REV), 2007(3)

56.    Mohiuddin S; Bessellink D; Farquhar C.Aust N Z J   Obstet Gynaecol] 2007 Dec; Vol. 47 (6), pp. 508-11. A

57.    UP TO DATE ,VER17.3.Laparoscopic surgery for ovulation induction in polycystic ovary syndrome

58.    Endocrine [Endocrine] 2006 Aug; Vol. 30 (1), pp. 27-33.

59.    Int J Gynaecol Obstet] 2010 Feb; Vol. 108 (2), pp. 143-7. Date of Electronic Publication: 2009 Nov 04.

60.    Hamed HO; Hasan AF; Ahmed OG; Ahmed MA. The Australian & New Zealand Journal Of Obstetrics & Gynaecology [Aust N Z J Obstet Gynaecol] 2007 Dec; Vol. 47 (6), pp. 508-11.

61.    Acta Medica Iranica, 46 (3): 203-206 ; 2008.MD L. safdarian 

62.    Hasan Y. Malkawi and Hussein S. Qublan. Obstet. Gynaecol. Res. Vol. 31, No. 2: 115–119, April 2005

63.    Molecular and Clinical Endocrinology and Oncology, Clinical and Experimental Medicine and Obstetrics and Gynaecology

64.    M.van Wely, N.Bayram, F.van der Veen and P.M.M.Bossuyt. Human Reproduction Vol.19, No.8 pp. 1741–1745, 2004

65.    Hamed HO; Hasan AF; Ahmed OG; Ahmed MA .Int J Gynaecol Obstet2010 Feb; Vol. 108 (2), pp. 143-7.

66.    Badawy A; Khiary M; Ragab A; Hassan M; Sherief L. Fertility And Sterility [Fertil Steril] 2009 Apr; Vol. 91 (4), pp. 1164-7.


 

Example-based machine translation

From Wikipedia, the free encyclopedia

Example-based machine translation (EBMT) is a method of machine translation often characterized by its use of a bilingual corpus with parallel texts as its main knowledge base, at run-time. It is essentially a translation by analogy and can be viewed as an implementation of case-based reasoning approach of machine learning.

At the foundation of example-based machine translation is the idea of translation by analogy. When applied to the process of human translation, the idea that translation takes place by analogy is a rejection of the idea that people translate sentences by doing deep linguistic analysis. Instead it is founded on the belief that people translate firstly by decomposing a sentence into certain phrases, then by translating these phrases, and finally by properly composing these fragments into one long sentence. Phrasal translations are translated by analogy to previous translations. The principle of translation by analogy is encoded to example-based machine translation through the example translations that are used to train such a system.

Example of bilingual corpus
English Japanese
How much is that red umbrella? Ano akai kasa wa ikura desu ka.
How much is that small camera? Ano chiisai kamera wa ikura desu ka.



http://en.wikipedia.org/wiki/Example-based_machine_translation

What is terminological and lexical consistency?

Terminological consistency means consistent use of terms within a text and across relevant texts. For example, term pin can mean штифт, палец, булавку, шплинт and a lot more. Some of these translations are interchangeable because the same part can be correctly called both штифтом и палец и шплинт. However, in technical text this translation should be selected once and forever (e.g. штифт) and use it through the text, otherwises the reader will be confused what object was meant.
There are often a few translators working on a text and each of them can translate a term correctly but different. In the space industry term feathering (rotation of a solar array) is correctly called флюгирование. Engineers, however more often use term “разворот” (a turn). Regardless of what option is selected it should be the same through the text.
But this is not all. Projects may contain many documents where same objects are mentioned. Naturally, one should seek consistency of terms in all such documents.
Lexical consistency is the same as the terminological one, only it deals not with special terms, but ordinary lexical units. For examples, last names or titles of publications can be translated differently (Вильям или Уильям), but should be the same as in all occurences in the documents.
Language Interface Inc. takes special measures to ensure terminological and lexical consistency. To achieve that a number of methods of software and organizational nature is used.

Machine translation, sometimes referred to by the abbreviation MT (not to be confused with computer-aided translation, machine-aided human translation (MAHT) or interactive translation) is a sub-field of computational linguistics that investigates the use of software to translate text or speech from one natural language to another.

On a basic level, MT performs simple substitution of words in one natural language for words in another, but that alone usually cannot produce a good translation of a text because recognition of whole phrases and their closest counterparts in the target language is needed. Solving this problem with corpus and statistical techniques is a rapidly growing field that is leading to better translations, handling differences in linguistic typology, translation of idioms, and the isolation of anomalies.[1]

Current machine translation software often allows for customization by domain or profession (such as weather reports), improving output by limiting the scope of allowable substitutions. This technique is particularly effective in domains where formal or formulaic language is used. It follows that machine translation of government and legal documents more readily produces usable output than conversation or less standardised text.

Improved output quality can also be achieved by human intervention: for example, some systems are able to translate more accurately if the user has unambiguously identified which words in the text are names. With the assistance of these techniques, MT has proven useful as a tool to assist human translators and, in a very limited number of cases, can even produce output that can be used as is (e.g., weather reports).

The progress and potential of machine translation have been debated much through its history. Since the 1950s, a number of scholars have questioned the possibility of achieving fully automatic machine translation of high quality.[2] Some critics claim that there are in-principle obstacles to automatizing the translation process.[3]

SYSTRAN

From Wikipedia, the free encyclopedia

SYSTRAN, founded by Dr. Peter Toma in 1968,[1] is one of the oldest machine translation companies. SYSTRAN has done extensive work for the United States Department of Defense and the European Commission.

SYSTRAN provides the technology for Yahoo! Babel Fish among others. It was used by Google's language tools until 2007.[2] SYSTRAN is used by the Dashboard Translation widget in Mac OS X.

Commercial versions of SYSTRAN can run on Microsoft Windows (including Windows Mobile), Linux, and Solaris. Historically, SYSTRAN systems used Rule-based machine translation (RbMT) technology. With the release of SYSTRAN Server 7 in 2010, SYSTRAN implemented a hybrid rule-based/Statistical machine translation (SMT) technology which was the first of its kind in the marketplace.[3]

As of 2008, the company had 59 employees of whom 26 are computational experts and 15 computational linguists.[4] The number of employees decreased from 70 in 2006 to 65 in 2007.[4]

History

With its origin in the Georgetown machine translation effort, SYSTRAN was one of the few machine translation systems to survive the major decrease of funding after the ALPAC Report of the mid-1960s. The company was established in La Jolla in California to work on translation of Russian to English text for the United States Air Force during the Cold War. Large numbers of Russian scientific and technical documents were translated using SYSTRAN under the auspices of the USAF Foreign Technology Division (later the National Air and Space Intelligence Center) at Wright-Patterson Air Force Base, Ohio. The quality of the translations, although only approximate, was usually adequate for understanding content.

The company was sold in 1986 to the Gachot family, based in Paris, and is now traded publicly on the French stock exchange. Its company headquarters is in Paris, while its U.S. headquarters is still in La Jolla.

During the dot-com boom, the international language industry started a new era, and SYSTRAN entered into agreements with a number of translation integrators, the most successful of these being WorldLingo.[citation needed]

Text types

From Wikipedia, the free encyclopedia

Textual types refer to the following four basic aspects of writing: descriptive, narrative, expository, and argumentative.

Descriptive text type

Based on perception in space. Impressionistic of landscapes or persons are often to be found in narratives such as novels or short stories. Example: About fifteen miles below Monterey, on the wild coast, the Torres family had their farm, a few sloping acres above the cliff that dropped to the brown reefs and to the hissing white waters of the ocean...

Purpose

Description is used in all forms of writing to create a vivid impression of a person, place, object or event e.g. to:

  • describe a special place and explain why it is special
  • describe the most important person in your life

Descriptive writing is usually used to help a writer develop an aspect of their work, e.g. to create a particular mood, atmosphere or describe a place so that the reader can create vivid pictures of characters, places, objects etc.

Features

Description is a style of writing which can be useful for a variety of purposes:

  • to engage a reader's attention
  • to create characters
  • to set a mood


Language

  • aims to show rather than tell the reader what something/someone is like
  • relies on precisely chosen vocabulary with carefully chosen adjectives and adverbs.
  • is focused and concentrates only on the aspects that add something to the main purpose of the description.
  • sensory description - what is heard, seen, smelt, felt, tasted. Precise use of adjectives, similes, metaphors to create images/pictures in the mind e.g. their noses were met with the acrid smell of rotting flesh.
  • strong development of the experience that "puts the reader there" focuses on key details, powerful verbs and precise nouns.

Narrative text type

Based on perception in time. Narration is the telling of a story; the succession of events is given in chronological order.

Purpose

The basic purpose of narrative is to entertain, to gain and hold a readers' interest. However narratives can also be written to teach or inform, to change attitudes / social opinions e.g. soap operas and television dramas that are used to raise topical issues. Narratives sequence people/characters in time and place but differ from recounts in that through the sequencing, the stories set up one or more problems, which must eventually find a way to be resolved. The common structure or basic plan of narrative text is known as the "story grammar". Although there are numerous variations of the story grammar, the typical elements are:

  • Setting—when and where the story occurs.
  • Characters—the most important people or characters in the story.
  • Initiating event—an action or occurrence that establishes a problem and/or goal.
  • Conflict/goal—the focal point around which the whole story is organized.
  • Events—one or more attempts by the main character(s) to achieve the goal or solve the problem.
  • Resolution—the outcome of the attempts to achieve the goal

The graphic representation of these story grammar elements is called a story map. The exact form and complexity of a map depends, of course, upon the unique structure of each narrative and the personal preference of the teacher constructing the map.

Types of Narrative

There are many types of narrative. They can be imaginary, factual or a combination of both. They may include fairy stories, mysteries, science fiction, romances, horror stories, adventure stories, fables, myths and legends, historical narratives, ballads, slice of life, personal experience. Features

  • Characters with defined personalities/identities.
  • Dialogue often included - tense may change to the present or the future.
  • Descriptive language to create images in the reader's mind and enhance the story.

Structure

In a Traditional Narrative the focus of the text is on a series of actions:

Orientation: (Introduction) in which the characters, setting and time of the story are established. Usually answers who? When? Where? E.g. Mr. Wolf went out hunting in the forest one dark gloomy night.
Complication or problem: The complication usually involves the main character(s) (often mirroring the complications in real life).
Resolution: There needs to be a resolution of the complication. The complication may be resolved for better or worse/happily or unhappily. Sometimes there are a number of complications that have to be resolved. These add and sustain interest and suspense for the reader.

Further more, when there is plan for writing narrative texts, the focus should be on the following characteristics:

  • Plot: What is going to happen?
  • Setting: Where will the story take place? When will the story take place?
  • Characterization: Who are the main characters? What do they look like?
  • Structure: How will the story begin? What will be the problem? How is the problem going to be resolved?
  • Theme: What is the theme / message the writer is attempting to communicate?

Expository text type

It aims at explanation, i.e. the cognitive analysis and subsequent syntheses of complex facts. Example: An essay on "Rhetoric: What is it and why do we study it?"


Argumentative text type

Based on the evaluation and the subsequent subjective judgement in answer to a problem. It refers to the reasons advanced for or against a matter.


Skopos theory: a retrospective assessment

 

Andrew Chesterman

                                        

[2010a      In W. Kallmeyer et al. (eds), Perspektiven auf Kommunikation. Festschrift für Liisa Tittula zum 60. Geburtstag. Berlin: SAXA Verlag, 209-225.]

 

1. Introduction

 

 

It is often said, especially by laymen, that translation does not really have a theory. Not true: it has lots! (Well, it depends what you want to call a theory; but still...)  But at least it does not have a general theory, right? Translation Studies has produced at best only a mixture of fragmentary theories. – This claim is not quite true either: we have several candidates which present themselves as general theories of translation. One them is skopos theory.

It is now about a quarter of a century since the publication of Reiß and Vermeer’s classic work, Grundlegung einer allgemeinen Translationstheorie (1984), and even longer since the earliest publications on a functional approach to translation. Skopos theory, as a particular type of general functional theory, seems fairly well established on the map of translation studies, and is duly mentioned in all the textbooks. But how well has it stood the test of time? My aim here is to offer a general retrospective assessment of the theory, also taking account of some more recent criticism.

 

2. Axiomatic assumptions

 

Any theory rests on basic assumptions that are not tested within a given research paradigm, but are taken as given, self-evident, based on common sense and logic. We must start from somewhere, after all. But of course we can always query these assumptions if we wish, standing outside the paradigm. Some of them may be only implicit, hidden. But good theories aim to make all the relevant assumptions as explicit as possible, for instance as axioms from which the rest of the theoretical claims can be deduced. Skopos theory is unusual among other theories of translation, in that it has this form of a deductive, “syntactic” theory based on a small number of explicit axioms. In the 1984 version, these are called “rules” (Regeln). I give them here in summarized form (in the original German, from Reiß and Vermeer 1984: 119), followed by some brief initial explications and comments.

 

1. Ein Translat ist skoposbedingt.

2. Ein Translat ist ein Informationsangebot in einer Zielkultur und –sprache über ein Informationsangebot in einer Ausgangskultur und –sprache.

3. Ein Translat bildet ein Informationsangebot nicht-umkehrbar eindeutig ab.

4. Ein Translat muß in sich kohärent sein.

5. Ein Translate muß mit dem Ausgangstext kohärent sein.

6. Die angeführten Regeln sind untereinander in der angegebenen Reihenfolge hierarchisch geordnet (“verkettet”).

 

              Ad 1: Skopos theory thus assumes that a translation always has a skopos (a purpose), even though this may not always be clear (ibid.: 21). This skopos may often differ from that of the source text (surely a useful point). The skopos is the highest determining factor influencing the translator’s decisions. Elsewhere (ibid.: 96), the rule is phrased: “Die Dominante aller Translation is deren Zweck.” The theory assumes that the skopos is oriented towards to the intended target recipients: all translations have such a readership; even if you cannot always specify them, there are always “there” (ibid.: 85). – I will return below to problems of definition.

              Ad 2: The theory assumes that language is embedded in culture. Translation is seen as a subtype of more general cultural transfer (Reiß and Vermeer 1984: 13). The “information offer” concept relates to the underlying theory of communication, whereby a sender “offers” information to a receiver. This information is assumed by the sender to be “interesting” to the receiver (ibid.: 76, 103), and, if the communicative act is successful, it will be interpreted by the receiver in a way that is compatible with the sender’s intention and does not give rise to a “protest” (ibid.: 67, 106).

              Ad 3: Translations are not normally reversible; and a given source text has many possible translations.

              Ad 4: Intratextual coherence is assumed to exist to the extent that the text makes sense to the receiver, that it is compatible with the receiver’s cognitive context, as in any form of communication. Note that rules 4 and 5 have a clear prescriptive form, unlike the others.

              Ad 5: This fidelity rule assumes that the translation represents the source text, in some way which is relevant to the skopos. The theory recognizes a range of equivalence types.

              Ad 6: This rule is of a different status from the others, and, as part of a general theory, problematic. We might at least want to query the order of rules 4 and 5 as being universally valid.

              Immediately after giving this summary, the authors claim that these rules are “probably” the only general rules of translation (ibid.: 120). All further development of the theory would then be filling in more detail, providing rules for the analysis of the target situation, establishing conditions for the selection of different translation strategies, and so on (ibid.: 85).

              A last initial comment: at the very beginning of the book, the authors define “theory”, quite reasonably, thus: “Unter ‘Theorie’ versteht man die Interpretation und Verknüpfung von ‘Beobachtungsdaten’” (ibid.: vii). This definition nevertheless seems to be rather at odds with the way they actually present their theory. The argument of the book does not start with empirical observations or inductive generalizations, but proceeds deductively. Examples are given to support claims, but many of them seem to be invented.

              In a later publication, Vermeer (1996: 12f) contextualizes skopos theory explicitly as a form of action theory. Here too he sets out a number of axioms (now called, in English, “theses”), as follows, ending at about the point where the previous list (above) began:

 

1. All acting presupposes a “point of departure”, i.e. an actor’s position in space and time, convictions, theories, etc., including their respective history.

2. All acting is goal-oriented.

3. From a variety of possibilities [...]  that action will be chosen which one believes one has the best reasons for choosing under the prevailing circumstances. The reason(s) may not be conscious for the actor.

4. Given the prevailing circumstances, an actor tries to reach the intended goal by what seem to him the/an optimal way, i.e., for which he believes he has the best overall reason(s).

5. Translating is acting, i.e. a goal-oriented procedure carried out in such a way as the translator deems optimal under the prevailing circumstances.

6. Thesis 5 is a general thesis valid for all types of translating [including interpreting].

7. In translating, all potentially pertinent factors (including the source text on all its levels) are taken into consideration as far as the skopos of translating allows and/or demands. [Emphasis original]

8. The skopos of (translational) acting determines the strategy for reaching the intended goal.

 

One might wonder about the apparent underlying assumption here that human behaviour is necessarily always rational – if these axioms are supposed to be descriptive (on which more below). Another underlying assumption, to which we shall return, is the assumption of optimality: that the translator (always) acts in an optimal way.

 

3. Conceptual contribution

 

Quite apart from any other merits, a theory may contribute new concepts to a field. These may aid theoretical thinking in general, as well as description and explanation, and may be taken up and adapted by other theories. New theoretical concepts are interpretive hypotheses, to be tested pragmatically in use (see further e.g. Chesterman 2008). Two aspects of this potential conceptual contribution will be mentioned here, beginning with the central concepts themselves.

 

3.1. Key terms and conceptual distinctions

 

Some of the earliest criticism of skopos theory had to do with some of its definitions, or the lack of them (see Koller 1990, on functional theories more generally; Kelletat 1986; Hebenstreit 2007). We can also ask whether the relation between the set of terms and the set of necessary concepts is an appropriate one. Are there too many terms, or too few?

             Skopos is said to be a synonym of Zweck (purpose) or Funktion  (Reiss and Vermeer 1984: 96), but “function” itself is not explicitly defined in the same context. Perhaps it could be glossed as “intended effect”. But: effect on whom? Intended receivers, or any and all receivers? And intended by whom? Is it only the client’s intention that counts? What about the source author’s? The publisher’s? When does an effect begin, and end? What about heterogeneous effects? How do we actually measure effects? Furthermore, if skopos equals function, we may wonder why a new term is needed. Confusingly, the German term Funktion is used in several senses, including the mathematical one. Two of these senses do indicate an interesting distinction: “external function” is said to denote the translator’s general objective of making a living, whereas “internal function” refers to the skopos of a given translation (or translation process) (ibid.: 4). This external function seems very close to the term telos proposed in Chesterman and Baker (2008), to describe a translator’s ideological motivation for working as a translator, either generally as a career or on some specific, perhaps chosen, assignment.

              Later, Vermeer (1996: 7-8) seeks to distinguish three related concepts as follows: the intention is what the client wants to do; the skopos is what the translation is for; and the function is the “text purpose as inferred, ascribed by recipient”. But there remain problems here. Are these distinctions necessary? When might an intention clash with a skopos? Function, in particular, remains an unclear concept. Recipients are not a homogeneous set, and may well ascribe very different functions. Even a model reader may react differently on different occasions. And besides, actual reception should surely be distinguished from intended function. Both intentions and functions may be virtually impossible to access, particularly if the translations studied are distant in time or space. – The conceptual and terminological confusion here has not been resolved (see e.g. Nord 1997: 27f; Sunwoo 2007).

              Another problematic term is that of coherence, used both to refer to the similarity relation of equivalence between source and target, and to the intratextual interpretability of the translation itself. These seem very different concepts, and one wonders why the theory uses the same term. Since we already have “equivalence”, and this term is used in skopos theory too, why do we need a new term? We also already have “similarity”, if something looser than “equivalence” is wanted.

              A translation is defined in the second axiom as an offer of information about a source text (which is itself another such offer, about something else). This interpretation of the relation between source and target is much weaker than any notion of equivalence, weaker even than relevant similarity (although Reiss and Vermeer do refer occasionally to the offer as being a “simulating” one, e.g. p. 80, 105). It does not appear to constrain the “offer” in any way, except insofar as the offer is assumed to be “interesting” to the receivers and is “coherent” with the source text. Here again we can ask: does this term really earn its place?

Regarding the German term Translation itself, we can appreciate the way in which skopos theory (following a German tradition in Translation Studies) uses this to cover both written and oral translation: this is a neat solution we have not managed to imitate in English, and which has subsequently been widely accepted. There will, however, always be argument about the appropriate extension of the term. Kelletat (1986) and Koller (1990) think the skopos notion of translation is too broad because of the way it downgrades the importance of the source text and thus allows very free translations, adaptations etc., within the concept. Kelletat (1986: 15) even suggests the Reiss/Vermeer definition would include the whole of Latin literature! In my view, on the contrary, it is too narrow, if it is taken to exclude non-optimal translations.

              The theory’s use of the term “adequacy” (Adäquatheit) also merits a comment. The term was already familiar from other approaches, particularly Toury’s (e.g. 1980). But skopos theory defines it differently, not as a retrospective relation of closeness between target and source but as a prospective one between the translation, the source text and the skopos (Reiss and Vermeer 1984: 139). This skopos-sense of adequacy is so easily confused with the Toury-sense that scholars now either have to specify which sense is intended or give up using the term altogether. It is risky to give a new sense to an already established term.

              Skopos theory, like other functional approaches, has also contributed to a more differentiated conceptualization of the agents involved in the translation process. Instead of simply having a sender and a receiver, we have learned to distinguish between writer, client, translator, publisher, recipient, addressee and so on. In this sense, skopos theory has helped to shift the discipline towards a more sociological approach.

 

3.2.  Underlying metaphorical structure

 

A good theory’s concepts do not exist in isolation, but in a network of relations. This network may be more or less consistent in terms of its metaphorical structure. Martín de León (2008) has recently drawn attention to some interesting problems in the underlying metaphorical conceptualization of skopos theory. She argues that the theory combines two different metaphors: TRANSFER and TARGET. This suggests a lack of conceptual consistency, insofar as the metaphors are incompatible.

The TRANSFER metaphor describes the movement of an object from A to B, and assumes that the object (or some essence of it) does not change en route. This means assuming some kind of equivalence, of course. As an underlying metaphor for translation (visible in the etymology of this word), it normally needs to reify some notion of meaning (referred to as the message in Holz-Mänttäri 1984). The client’s intention might also be regarded as an “object” that is to be preserved. However, the view of a translation as merely an “offer of information” about the source text appears to go against the TRANSFER metaphor.

The theory’s notion of intertextual coherence also relates to this metaphor, albeit loosely. But how valid is this assumption that meaning is “there” in the text? Several contemporary models of cognition would argue that meaning always emerges via a process of interpretation, a process which depends on multiple variables and is not completely predictable (see e.g. Risku 2002). – In my view, both these positions are overstated. Surely some meanings are more obviously, objectively “there” in a text, while others are much less so and are open to interpretive variation. If no meanings were objectivizable at all, there would be no work for terminologists and no-one would dare to step into a plane.

The TARGET metaphor on the other hand describes a process from a source along a path to a goal. It does not assume an unchanged, reified message. It implies that the translator can participate in constructing the meaning of the message and thus highlights notions of intentionality and rationality. Skopos theory stresses the expertise and responsibility of the translator to select what needs to be translated and to translate it in the most appropriate manner. But this metaphor also prompts questions. Suppose a given process or action does not have a single goal but multiple ones, perhaps regarding heterogeneous receivers? And where actually is a goal located? Strictly speaking, the goal is not in the text but in the mind of the initiating agent, for whom the translation is merely a means to achieve a goal or goals. Further: where in the theory is there any space for an assessment of the goals themselves? Is it really enough to say that any end justifies the means? – We will take up the ethical dimension of this argument below.

 

 

4. Ontological  status of the theory

 

Perhaps the most debated problem of skopos theory has been its unclear ontological status. Does it aim to be a descriptive theory (of what is) or a prescriptive one (of what should be)? Does it describe a real world or an ideal, optimal one?

              This ambiguous status is already apparent in its axioms: axioms four and five are openly prescriptive, but the others are not. Reiss and Vermeeer say that there is no such thing as “the best” translation for a given source text. “Es gibt nur das Streben nach Optimierung unter den jeweils gegebenen aktuellen Bedingungen” (1984: 113). – This is an interesting formulation. The “es gibt” looks like an existential, descriptive claim: it is a fact that translators strive, that they do their best. Well, how valid is this fact? We could reply that good translators do indeed do their best, most of the time, but surely there must also be many translators who merely do the minimum, at least sometimes. Professionals must often satisfice, after all. And there are many bad translators, of course (if a translator is anyone who does a translation, as a general theory should surely assume).

              It seems to me to be clear that skopos theory is essentially prescriptive, although it has some descriptive assumptions. It aims to describe how good translators, expert professionals, work; what good translations are like. It describes an ideal world (see also Chesterman 1998). Vermeer has acknowledged this (Chesterman 2001), saying that the theory seeks to describe optimal cases. Elsewhere, however, he also seems to suggest that functional theories in general are both descriptive and prescriptive:

 

Skopos theory is meant to be a functional theoretical general theory covering process, product and, as the name says, function both of production and reception. As a functional theory it does not strictly distinguish between descriptive and (didactic) prescription. (Vermeer 1996: 26n)

 

Although the term “functional” remains problematic, I find this claim curious. Consider for instance the analysis of the reception of translations in a given culture in a given period. This would be an analysis of how the translations “functioned” in the target culture (data might include all kinds of responses, critical reviews, library loans, size and number of editions published, allusions to the translations in other writings, use of the translations as source texts for further translations, or as literary influences; sales of commercial products advertised by the translations; changes in the social, political, religious or ideological conditions; and so on). The analysis would not need to be prescriptive in any way. Even if the analysis compared the reception with the inferred intentions of different clients, this would not imply a prescriptive approach.

              On the other hand, there is one obvious way in which prescriptive claims can be viewed descriptively, and that is by formulating them as predictive hypotheses, as argued in Chesterman (1999). Vermeer actually does precisely this at one point (1996: 31): “if you translate in such and such a way then y will happen”. Such predictions can then be tested in the normal way, and the results can be generalized in the form of guidelines which, if followed, are reliably assumed to lead to translations which do not give rise to negative feedback (“Protest” in skopos-theoretical terms). This, of course, is precisely what translator training courses teach. It is also what skopos theory aims to do. If you keep the skopos in mind, and translate accordingly, the result will be better than if you neglect the skopos.

             

 

5. Empirical status of the theory

 

As presented, skopos theory is not founded on a search for empirical regularities. This point has been made by many critics (e.g. Koller 1995: 215). We can nevertheless consider how its various assumptions and claims might be tested empirically. It is striking that very little such testing has actually been done. What kind of evidence would falsify or weaken its claims? I will first consider the theory’s descriptive adequacy, then comment on its explanatory adequacy and possible testable consequences.

 

5.1. Descriptive adequacy

 

Axioms two and three in the original list above are descriptive. Axiom two, on translation as an offer of information, is definitional. It is an interpretive hypothesis, which can be glossed something like this: ‘in this theory, we claim that a translation is usefully interpreted as ...’. As such, the claim is not falsifiable, but is testable pragmatically, i.e. in use (see further Chesterman 2008). Has this interpretation been widely adopted and led to further hypotheses? Not notably, it seems. On the contrary, it has aroused some criticism, as it seems to allow the concept of translation to expand too far (e.g. Kelletat 1986).

              Axiom three states that translations are not reversible. This claim can certainly be tested empirically, via back-translation. In my view, the claim is too extreme. It would surely be more accurate to say that the smaller the unit of translation, the more reversible it is; that in cases of standardized translations – e.g. in multilingual  glossaries of special fields or in the names of institutions, or in many idioms and proverbs, in numbers, etc. – reversibility may well be the norm. In other words, the claim needs to be restricted, made subject to other conditional factors such as size of translation unit, text type, skopos, and so on.

              There have been a few empirical studies recently which question some of the other basic assumptions of skopos theory. Koskinen (2008) examines the working conditions of EU translators. One of her findings is that in many cases, EU translations that are not intended for the general public are not directed at a target culture at all, but are oriented by the needs of the source institution (99-100). This goes against the skopos theory assumption that a translation should have optimal functionality for target culture addressees. However, this type of EU case is not evidence against the idea that a translation is primarily determined by its skopos.  Here, the skopos is simply not a target-oriented one. Interestingly, Koskinen points out that the special requirements of this kind of translation are experienced as particularly problematic by translators who have been trained in a functional approach: their translation brief seems to conflict with the target-oriented way in which they have been trained to think.

Furthermore, many professional translators do not work as autonomous individuals but as members of a team of experts, including terminologists, subject specialists, revisers, copyeditors and so on. Such conditions do not always support the skopos theory assumption that it is the translator who ultimately decides how to translate, as the expert. (“Er entscheidet letzten Endes, ob, was, wie übersetzt/gedolmetscht wird.” Reiß and Vermeer 1984: 87.) One recent study illustrates this well: Nordman (2009) examines the complex process of Finnish-Swedish translation in the bilingual Finnish Parliament, and highlights interesting disagreements between the translator’s preferences and those of revisers or legal experts, and how these are resolved. The translators and revisers she studied seem to have different norm priorities. It is not always the translator’s views that prevail.

Even in some literary translation the priority of the translator’s expertise has been questioned. In a questionnaire study dealing with poetry translation, Flynn (2004) queries the status of some of the factors which skopos theory assumes, including that of the dominance of the translator’s own expertise. Flynn found that the situational factors affecting the final form of the translation are more like sites of confrontation between the various agents involved, including publishers and proof-readers as well as translators. The translator does not necessarily always have the final say. Flynn’s results admittedly concern a particular type of translation only, in a particular (Irish) context; but again, we can point out that a general theory should be able to cope with all types.

              As another example of evidence against the assumption that it is the expert translator who makes the final decisions I cite an ongoing PhD project by Julia Lambertini Andreotti at Tarragona. She is a qualified court interpreter working with Spanish and English in California. The ethical code there requires that interpreters make no alteration to the register of the legal jargon as they translate. But since many of the clients are not well educated, they simply do not understand the legal terminology, and so do not understand what they are asked. As communication experts, the interpreters naturally wish to adapt the register so that the clients can understand, but this is not allowed. The interpreters are simply not permitted to act as skopos theory assumes.

One might argue that all such examples are cases where a translator is forced to act under duress, against the council of his own expertise, and thus in non-optimal conditions. They would thus fall outside the scope of skopos theory. Reiß and Vermeer explicitly exclude instances of “Translation unter Zwang” (1984: 101). – But there are multiple kinds and grades of duress, including  unrealistic deadlines, legal constraints etc., which characterize much real-world translation and interpreting. Indeed, if there are in fact more non-optimal cases than optimal ones, skopos theory itself would deal only with special cases – surely not the intention of the skopos theorists. A general theory should be general enough to encompass all cases.

              From another point of view, note should be taken of studies on how translators perform under time pressure (e.g. Hansen 2002). These studies suggest that when professional experts work under unusual time pressure, they tend not to waste time pondering about the skopos or the target audience but simply stay on the surface of the text, translating fairly literally, without reformulations or other major shifts which might actually be appropriate for the readership. Here again we have professionals working in a non-optimal situation, without sufficient time for normal working procedures. Under these conditions, the skopos assumptions seem not to represent what actually happens.

Research such as these studies underlines the way in which skopos theory relates more to an ideal, optimal world than to the real and often suboptimal world of everyday translation. In this sense, some of the general descriptive claims and assumptions of the theory can easily be falsified, or forced into more conditioned formulations – if they are supposed indeed to apply to all translation, not just optimal translation done in optimal working conditions. And what about the undeniable existence of a great many really bad translations? These are nonetheless also translations, of a kind; but they are completely excluded from skopos theory. From the point of view of descriptive adequacy, then, the theory is inadequate. But if it is taken as a prescriptive theory, of course, this is not a valid criticism.

 

 

5.2. Explanatory adequacy

 

The first axiom (in the German list above) is a causal one. From the point of view of the production of a translation, it states that the skopos is the most important conditioning factor. This has obvious prescriptive relevance. But retrospectively, as an answer to the question “why is this translation like this?”, the axiom formulates a causal explanation. The most important reason why a translation (or, modified: an optimal translation) is as it is, is its skopos. This claim gives rise to several points.

              Implied in the axiom is the assumption that every translation has a skopos in the first place. Is this assumption testable? Could we in principle refute the claim by finding a translation that does not have a skopos? Perhaps not. Skopos theorists would say that the skopos is always already there, even if not well defined or even definable. Some scholars (e.g. Kohlmayer 1988) have argued that literary translations do not have a skopos; it is certainly not easy to be precise about the skopoi of literary texts.

              The theory does not assume that the skopos is the only cause, merely that it is the dominant one. How might this dominance be measured? What other causes might be relevant? One might counter-argue that under some conditions the skopos dominates, under other conditions some other cause (perhaps these other conditions would be non-optimal ones?). Kelletat (1986) points out that Reiß and Vermeer fail to show how different translation traditions, as well as different skopoi, are themselves affected by historical conditions.

Recall Aristotle’s four causes: the skopos cause corresponds to his “final”, teleological one. It has been argued (e.g. by Pym 1998: 148f) that skopos theory overvalues this teleological cause at the expense of the others. The skopos does take account also of Aristotle’s formal cause (the target-culture norms), but what about the efficient cause (the mind and body of the translator plus computer etc.) or the material cause (the source text, perhaps also the constraints of the target language itself)? Pym argues that by imputing purpose to a text, skopos theory neglects the socially determined individuals who are actually doing the translation. Skopos theory also avoids the problem situation in which client and translator differ about the skopos, or where there might be a conflict of loyalty. True, Nord’s version of skopos theory (Nord [1988] 1991 and later versions) gives more weight to the material cause by focusing strongly on the analysis of the source text. But Vermeer does not agree with Nord’s introduction of the notion of loyalty (see further below).

              It is often pointed out in textbooks that skopos theory helped to dethrone the source text as the dominating causal factor determining the form of a translation. It has now placed the skopos on the vacant throne. But perhaps we would achieve greater explanatory adequacy, more nuanced explanations, if we recognized a range of explanatory variables including norms, personal preferences, special situational constraints and so on, all of which impinge on the translators decisions (see e.g. Brownlie 2003). The relative strength of the different variables in a given case would then depend on the circumstances. This would also allow for non-optimal working conditions, and indeed non-optimal translators. Any generalization about the overall dominance of one independent variable or another could only be based on a wide range of comparative empirical studies.

             

5.3. Testable consequences

 

A deductive theory such as skopos theory, if it claims to be empirical, should also generate hypotheses that can be tested and potentially falsified. The theoretical claims should have testable consequences. Curiously, the theory does not seem to have been very productive in this respect. One reason may be the difficulty of operationalizing its central concepts and claims.

              One predictive hypothesis that does arise very naturally from the theory’s premises is that if the skopos is different, the translation will be different. This can easily be tested: a given source text is translated twice, each time with a different skopos. Nordberg (2003) studied precisely this situation, but focused on differences between professionals and non-professionals rather than skopos-determined differences.

              Other hypotheses can be proposed, which (as far as I am aware) have not been explicitly tested.

              – If a translation is deemed bad, the main reason (a reason?) will be that it does not meet the skopos. (Also obvious, surely.)

              – The more the translator pays attention to the skopos, the better the translation will be. (Another obvious one.)

              – Skopos-type correlates more closely than source-text type with equivalence-type. This one would be more interesting. It would test the relative causal force of skopos vs source text-type on the source-target relation. But there is a problem here. We have typologies of text types, and typologies of equivalence, but, surprisingly, no generally accepted typology of skopoi. Reiß and Vermeer give random examples, but no systematic typology. Would  such a typology necessarily be culture-bound and thus not part of a general theory? Surely not, at least no more than other typologies used in translation research. Prunč (1997a) proposes seven prototype classes, but these are in fact classes of translations, not skopos types. They range from non-translation via pseudotranslation to homologous, analogous, dialogic (involving more interpretation) and triadic (intervening, e.g. feminist) to diascopic translation (gist translation, commentary). Nord (1997) proposes two basic “translation functions”, documentary and instrumental; but here too we are dealing with types of translation rather than skopoi.

In a different article, Prunč (1997b) makes a useful distinction between implicit and explicit skopos. The implicit skopos is defined as the lowest common denominator, the default skopos compatible with the current translation norms and the prevailing translation tradition. The explicit skopos then states, where necessary, any divergence from the implicit skopos. But no typology of explicit skopoi is offered here.

Wagner (in Chesterman and Wagner 2002: 45) does offer one specific skopos typology, for use in the EU. These are: 

 

              For information, not for publication

              For publication [a very broad  category]

              For advertising and marketing

              For use as a legal document

              For text scanning and abstracting

 

              The big gap is the lack of research on how a given skopos or skopos type might actually correlate with given translation strategies or techniques. Even within given language pairs, this would be interesting and useful. Reiss and Vermeer (1984: 85) say that a “complete” translation theory would give “rules” for the analysis of the target recipient situation and how this then conditions the translation strategy. But skopos-based research has not developed much in this direction. One wonders why. (For a recent attempt to operationalize the skopos concept, see Sunwoo 2007.) We look in vain for testable hypotheses of the form: if the skopos is (type) X, professional translators tend to choose general strategies ABC. Or: in the case of translations from language S to language T (under conditions PQR), translators tend to realize skopos-determined strategy A as techniques / translation solutions DEF.

 

 

6. The ethical dimension

 

Partly in order to counter criticisms that skopos theory is too target-oriented and underestimates the value of the source text, Nord (e.g. 1997: 123f) introduced the concept of loyalty, which is defined as meaning loyalty to all the people concerned on both side of the communication exchange, including the source author and sender. Vermeer does not like this development, as he thinks it brings in an unwanted ethical dimension. A scientific theory is value-free, he argues.

 

It has been argued that translation involves an ethical aspect. However, I amof the opinion that ethics must not be mixed up with general theoretical considerations about other subjects. Science should be value-free (wertfrei). (Vermeer 1996: 107)

 

Toury apparently agrees (1995: 25).

However, I think this position is untenable. In a classic article, Rudner (1953) showed that science can never be value-free. Value judgements are made all the time: in selecting “interesting” research problems (i.e. those that have value...), evaluating the evidence and counter-evidence for hypotheses, prioritizing research goals, and so on. Skopos theory highlights the expertise of the translating agent, who makes decisions. It seems to me that any such theory must include an ethical dimension, at least insofar as ethical issues influence the agent’s decisions. (See also Martín de León 2008.) Furthermore, one could argue that a functional theory of translation should also cover the possible general ends which translations serve, their ultimate functions, as it were: some translations are surely more worth doing than others, for instance, not in terms of pay but in terms of the ethical value of the end product (cf. voluntary, activist translation, for example). It is all very well to say that if we want X we should do A (rather than B, for instance); and we can of course test this hypothesis, checking to see whether A or B is a better means to attain X. The only criterion here seems to be that of effectiveness. But suppose we ask who wants X? And for what reasons? For what further end is X itself a means? And who does not want X?

The lack of this dimension in skopos theory, where any end is apparently as good as any other, has led to the theory being associated with a kind of robotic, unthinking translation process, which dehumanizes the translator. Baker (in Chesterman and Baker 2008: 21-22) puts this view as follows:

 

We soon configure something like skopos theory as a narrative in our minds: the theory evokes (for me at any rate) an industrialized, affluent society populated by clients and highly professional translators who belong to the same ‘world’ as their clients, who are focused on professionalism and making a good living, and who are highly trained, confident young men and women. These professional translators and interpreters go about their work in a conflict-free environment and live happily ever after. They do not get thrown into Guantánamo or shot at in Iraq, and they do not end up on the border of Kosovo and Albania in the middle of a nasty war, where they would have to decide whether or not to fulfil their commission at the expense of treating potential victims with compassion and respect.

 

Prunč (1997b) seeks to counter this criticism that the skopos view of translation risks being interpreted as totalitarian. He stresses how skopos theory can account for cooperation between agents, and expands the loyalty concept to include the translator’s loyalty to him/herself.

              Perhaps Vermeer is equating value-freedom with rationality? Rudner concluded that value-freedom is often confused with objectivity. He argued:

 

What is being proposed here is that objectivity for science lies at least in becoming precise about what value judgments are being and have been made in a given inquiry – and even, to put it in its most challenging form, what value decisions ought to be made; in short that a science of ethics is a necessary requirement if science’s progress towards objectivity is to be continuous. ([1953] 1998: 497)

 

 

7. The competition?

 

In assessing a theory (or indeed a hypothesis) one also compares it to competing theories. The closest competitor to skopos theory is Justa Holz-Mänttäri’s theory of translational action (1984). Indeed, this is so close, albeit with a different terminology, that they are often considered to be variants of the same framework (Vermeer 1996: 61f). Some of the criticism of skopos theory has also been directed at Holz-Mänttäri’s work (e.g. Koller 1990).

              A more interesting comparison might be made with relevance theory, in its application to translation (starting with Gutt 1991). A detailed analysis would take up more space than is available here, so a few comments must suffice.

              In their discussion of the notion of the offer of information,  Reiß and Vermeer (1984: 76, 103) write that this “offer” is assumed by the sender to be “interesting” to the receiver. I.e. the sender thinks that the information contains something that is “new” to the receiver, something that will have some effect, which will somehow change the existing state of affairs in the receiver’s world. – This formulation suggests the central concept of relevance, as understood in relevance theory. It would seem that skopos theory sees itself as being much broader than relevance theory, including relevance-theoretical insights and much more (Vermeer 1996: 65-68).

              Relevance theory clearly aims to be descriptive and indeed explanatory, not prescriptive. But there does seem to be a conceptual overlap, perhaps more than Vermeer seems to accept (see Vermeer 1996: 47f, and his comments in Chesterman 2001). Both theories assume that human action is rational, and both give importance to the receiver’s side. The two theories differ in the extension of their object of study: relevance theory excludes very free translations, and so-called multilingual descriptions, which skopos theory would include (Vermeer 1996: 63). Skopos theory also allows a deliberate change of skopos from that of the source text, which would seem to be excluded by Gutt’s application of relevance theory.

             

 

8. Concluding remarks

 

Skopos theory has proved itself to be pedagogically invaluable, as a prescriptive theory; I cannot imagine training translators without using the idea of the skopos. But as an empirical theory seeking to describe and explain translation phenomena in the real world, it is weak, precisely because it relies on an optimal set of working conditions with optimally competent translators. One of the most serious problems in the real translation world, however, is the prevalence of poor translations, coupled with poor working conditions and low pay. These issues are not addressed by skopos theory.           

              In terms of its productivity, the theory has been somewhat disappointing. It has not generated a substantial body of research proposing and testing new hypotheses derived from the theory, nor significally developed its conceptual apparatus. True, it has been expounded in numerous textbooks, and applied in numerous training programmes and notably in translation criticism (e.g. Ammann 1990). It has succeeded in giving some theoretical weight to an intuitively sensible idea ­– that translators should consider the purpose of their translations – and certainly helped to shift the focus of theoretical thinking away from equivalence towards other relevant factors and agents which affect the translation process. It has thus helped, perhaps paradoxically, to make translation theory more realistic. And it has prompted some of us to ponder more deeply what we mean by a theory.

                           

 

References

 

Ammann, M. 1990. Anmerkungen zu einer Theorie der Übersetzungskritik und ihrer praktischen Anwendung. TextConText 5, 209-250.

Andreotti, J. L. (in progress). Comprehension of legal discourse in interpreted proceedings. Ongoing PhD thesis, Universitat Rovira I Virgili, Tarragona.

Brownlie, S.  2003. Investigating explanations of translational phenomena. Target 15, 1, 111-152.

Chesterman, A. 1998. Review of Hans. J. Vermeer, A Skopos Theory of Translation. Target 10, 1, 155-188.

Chesterman, A. 1999. The empirical status of prescriptivism. Folia Translatologica 6, 9-19.

Chesterman, A. 2001. Skopos and after. An interview with Hans J. Vermeer. Across 2, 1, 133-138.

Chesterman, A. 2008. The status of interpretive hypotheses. In G. Hansen et al. (eds), Efforts and Models in Interpreting and Translation Research. Amsterdam: Benjamins, 49-61.

Chesterman, A. and M. Baker 2008. Ethics of renarration. CULTUS 1, 10-33.

Chesterman, A. and E. Wagner 2002. Can Theory Help Translators? Manchester: St. Jerome Publishing.

Flynn, Peter 2004. Skopos Theory: An ethnographic enquiry. Perspectives 12, 4, 270-285.

Gutt, E.-A. 1991. Translation and Relevance. Cognition and context. Oxford: Blackwell.

Hansen, Gyde 2002. Zeit und Qualität im Übersetzungsprozess. In G. Hansen (ed.), Empirical Translation Studies: process and product. Copenhagen: Samfundslitteratur, 29-54.

Hebenstreit, G. 2007. Defining patterns in Translation Studies. Target 19, 2, 197-215.

Holz-Mänttäri, J. 1984. Translatorisches Handeln. Helsinki: Suomalainen Tiedeakatemia.

Kelletat, A. F. 1986. Die Rückschritte der Übersetzungstheorie. Vaasa: Vaasan korkeakoulu.

Kohlmayer, R. 1988. Der Literaturübersetzer zwischen Original und Markt. Eine Kritik funktionalistischer Übersetzungstheorien. Lebende Sprachen 33, 4, 145-156.

Koller, W. 1990. Zum Gegenstand ger Übersetzungswissenschaft. In R. Arntz and G. Thome (eds), Übersetzungswissenschaft. Ergebnisse und Perspektiven, Festshcrift für Wolfram Wilss zum 65. Geburtstag. Tübingen: Narr, 19-30.

Koller, W. 1995.  The concept of equivalence and the object of Translation Studies. Target 7, 2, 191-222.

Koskinen, Kaisa 2008. Translating Institutions. An Ethnographic Study of EU Translation. Manchester: St. Jerome Publishing.

Martín de León, Celia 2008. Skopos and beyond. A critical study of functionalism. Target 20, 1, 1-28.

Norberg, U. 2003. Übersetzen mit doppeltem Skopos. Uppsala: Uppsala Universitet.

Nord, C. [1988] 1991. Textanalyse und Übersetzen. Theorie, Methode und didaktische Anwendung einer übersetzungsrelevanten Textanalyse. Heidelberg: Groos.

Nord, C. 1997. Translating as a Purposeful Activity. Manchester: St. Jerome Publishing.

Nordman, L. 2009. Lagöversättning som process och produkt. Helsinki: Institutionen för nordiska språk och nordisk litteratur, Helsingfors universitet

Prunč, Erich 1997a. Versuch einer Skopostypologie. In N. Grbic and M. Wolf (eds), Text – Kultur – Kommunikation. Tübingen: Stauffenburg, 33-52.

Prunč, E. 1997b. Translationskultur . Versuch einer konstruktiven Kritik des translatorischen Handels). TEXTconTEXT 11, 2, 99-127.

Pym, A. 1998. Method in Translation History. Manchester: St. Jerome Publishing.

Reiss, K. and H.J. Vermeer 1984. Grundlegung einer allgemeinen Translationstheorie. Tübingen: Niemeyer.

Risku, H. 2002. Situatedness in Translation Studies. Cognitive Systems Research 3, 3, 523-533.

Rudner, R. 1953. The scientist qua scientist does make value judgements. Philosophy of Science 20, 1-6. Reprinted in E.D. Klemke et al (eds) 1998, Introductory Readings in the Philosophy of Science. 3rd edition. Amherst, NY.: Prometheus Books, 492-498.

Sunwoo, M. 2007. Operationalizing the translation purpose (Skopos). MuTra conference proceedings: LSP Translation Scenarios. Available at http://www.euroconferences.info/proceedings/2007_Proceedings/2007_Sunwoo_Min.pdf (Accessed 16.4.2009).

Toury, G. 1980. In Search of a Theory of Translation. Tel Aviv: Porter Institute.

Toury, G, 1995. Descriptive Translation Studies and Beyond. Amsterdam: Benjamins.

Vermeer, H.J. 1996. A skopos theory of translation. (Some arguments for and against) Heidelberg: TEXTconTEXT.

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