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OBJECTIVE: To describe the intraoperative and postoperative implications arising from the unexpected diagnosis of a Müllerian anomaly during the surgical management of an ectopic pregnancy. DESIGN: Video article. SETTING: Academic center. PATIENT(S): A 39-year-old nulligravid woman with anovulation and irregular menstrual cycles presented to the office. Her urine pregnancy test result was incidentally positive; the serum ß-human chorionic gonadotropin level was 5,644 mIU/mL. Outpatient transvaginal ultrasonography demonstrated a 2.1 × 1.7 × 2.2-cm thick-walled structure in the left adnexa without an intrauterine pregnancy. These findings were highly suspicious for a left tubal ectopic pregnancy. The patient was consented for laparoscopy with planned left salpingectomy. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (e.g., PubMed, ScienceDirect, and Scopus), and other applicable sites. INTERVENTION(S): Diagnostic laparoscopy did not show an obvious left tubal ectopic pregnancy. Instead, a right unicornuate uterus with a dilated rudimentary left uterine horn was seen. Both fallopian tubes and ovaries appeared normal. These laparoscopic findings were consistent with an ectopic pregnancy in the rudimentary horn. However, in the absence of informed consent for a hemihysterectomy and no evidence of ectopic rupture or bleeding within the pelvis, we decided to proceed with excision of the ectopic pregnancy from the uterine horn. An incision was made over the anterior surface of the uterine horn, and the pregnancy sac was dissected from the underlying myometrium and excised in its entirety. Left salpingectomy was also performed. The patient was discharged home the same day, and her ß-human chorionic gonadotropin levels decreased to <5 mIU/mL within 28 days of surgery. MAIN OUTCOME MEASURE(S): Complete resolution of a left rudimentary uterine horn ectopic pregnancy through surgical excision of the pregnancy sac without hemihysterectomy. RESULT(S): Postoperative hysterosalpingography demonstrated a right unicornuate uterus with normal fill and spill of the right fallopian tube. Magnetic resonance imaging of the pelvis confirmed the findings of a right unicornuate uterus with a noncommunicating left rudimentary uterine horn that did not contain any endometrial tissue. Thus, the patient did not require an interval hemihysterectomy. She underwent letrozole and intrauterine insemination treatment 5 months after the initial surgery, which resulted in a clinical intrauterine pregnancy. However, this pregnancy was terminated in the early second trimester because of findings of trisomy 18. She conceived naturally 1 year later, and this pregnancy resulted in a full-term vaginal birth at 39 weeks of gestation. CONCLUSION(S): Undiagnosed or unexpected Müllerian anomalies can impact the standard intraoperative and postoperative management of ectopic pregnancies.
Assuntos
Aborto Espontâneo , Aneuploidia , Humanos , Feminino , Gravidez , Córion/diagnóstico por imagem , Biomarcadores/sangue , AdultoAssuntos
Transferência Embrionária , Gravidez Múltipla , Feminino , Humanos , Gravidez , BlastocistoRESUMO
The study objectives were to determine whether ovarian morphology can distinguish between women with regular menstrual cycles, normo-androgenic anovulation (NA-Anov), and PCOS and whether body mass index (BMI)-specific thresholds improved diagnostic potential. Women with PCOS (biochemical and/or clinical hyperandrogenism and irregular cycles; N = 66), NA-Anov (irregular cycles without clinical and/or biochemical hyperandrogenism; N = 64), or regular cycles (controls; cycles every 21-35 days in the absence of clinical or biochemical hyperandrogenism; N = 51) were evaluated. Participants underwent a reproductive history, physical exam, transvaginal ultrasound, and a fasting blood sample. Linear regression analyses were used to assess the impact of BMI on ovarian morphology across groups. The diagnostic performance of ovarian morphology for anovulatory conditions, and by BMI (lean: <25 kg/m2; overweight: ≥25 kg/m2), was tested using Receiver Operating Characteristic (ROC) curves. Follicle number per ovary (FNPO) and ovarian volume (OV), but not follicle number per cross-section (FNPS), increased across controls, NA-Anov, and PCOS. Overall, FNPO had the best diagnostic performance for PCOS versus controls (AUCROC = 0.815) and NA-Anov and controls (AUCROC = 0.704), and OV to differentiate between PCOS and NA-Anov (AUCROC = 0.698). In lean women, FNPO best differentiated between PCOS and controls (AUCROC = 0.843) and PCOS versus NA-Anov (AUCROC = 0.710). FNPS better distinguished between NA-Anov and controls (AUCROC = 0.687), although diagnostic performance was lower than when thresholds were generated using all participants. In women with overweight and obesity, OV persisted as the best diagnostic feature across all analyses (PCOS versus control, AUCROC = 0.885; PCOS versus NA-Anov, AUCROC = 0.673; NA-Anov versus controls, AUCROC = 0.754). Ovarian morphology holds diagnostic potential to distinguish between NA-Anov and PCOS, with marginal differences in diagnostic potential when participants were stratified by BMI suggesting that follicle number may provide better diagnostic performance in lean women and ovarian size in those with overweight.
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OBJECTIVE: To report a clinical pregnancy resulting from intracytoplasmic sperm injection of prematurely ovulated oocytes retrieved from the posterior cul-de-sac. DESIGN: Case report. SETTING: Academic center. PATIENTS: A 40-year-old nulligravid woman underwent ovarian stimulation for in vitro fertilization (IVF). Daily injections of gonadotropin-releasing hormone antagonist were initiated on cycle day 8. A 10,000 IU dose of human chorionic gonadotropin was administered on cycle day 15 to trigger follicular maturation. The estradiol and luteinizing hormone levels on the trigger day were 1528 pg/mL and 2.4 mIU/mL, respectively. The patient underwent oocyte retrieval 35 hours after the trigger. Transvaginal sonography at the time of the retrieval revealed a large pocket of free fluid in the posterior cul-de-sac. Only 3 follicles measuring 10-12 mm were noted in both ovaries. No lead follicles were visualized. INTERVENTIONS: Aspiration of free fluid from the posterior cul-de-sac. MAIN OUTCOME MEASURES: Clinical pregnancy. RESULTS: The fluid in the posterior cul-de-sac was aspirated, and 3 mature oocytes were retrieved. Aspiration of the smaller ovarian follicles measuring 10-12 mm did not yield oocytes. All mature oocytes retrieved from the posterior cul-de-sac were fertilized with intracytoplasmic sperm injection. Three cleavage-stage embryos were transferred 3 days later. A single intrauterine pregnancy with cardiac activity was confirmed at a gestational age of 7 weeks. CONCLUSIONS: In the setting of premature ovulation, aspiration of free fluid from the posterior cul-de-sac can result in the retrieval of mature oocytes, which may result in clinical pregnancies.
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OBJECTIVE: To report the utility of combined transvaginal and transabdominal oocyte retrieval in a patient with an ectopic ovary and unicornuate uterus. DESIGN: Video case report with demonstration of oocyte retrieval technique. SETTING(S): University-affiliated fertility center. PATIENT(S): A 35-year-old woman, gravida 0, with a 6-month history of infertility who presented to our center for fertility evaluation. Hysterosalpingography revealed a left unicornuate uterus and patent left fallopian tube magnetic resonance imaging and laparoscopy showed a right ectopic ovary located in the upper abdomen. Her partner was a 36-year-old male with isolated teratozoospermia. The couple did not conceive with intrauterine insemination. INTERVENTION(S): Ovarian stimulation for in vitro fertilization (IVF). Transvaginal retrieval of oocytes from the right ovary was not deemed possible due the anatomic location of the ovary, intervening blood vessels, and limited mobility of the ovary. Institutional review board approval was not required for this case report as per our institution's policy; patient consent was obtained for publication of the case. MAIN OUTCOME MEASURE(S): Transabdominal retrieval of oocytes from the right ovary and transvaginal retrieval of oocytes from the left ovary. RESULT(S): The couple underwent two IVF cycles. Nine oocytes were retrieved during the first IVF cycle: seven transabdominal (right ovary) and two transvaginal (left ovary). All oocytes were mature, and five blastocysts were cryopreserved. Eight oocytes were retrieved during the second IVF cycle, of which five oocytes were retrieved transabdominally from the right ovary, and three oocytes were retrieved transvaginally from the left ovary. All oocytes were mature, and four blastocysts were cryopreserved. A single thawed embryo was transferred in the natural menstrual cycle, which resulted in the live birth of a full-term baby boy weighing 2,410 grams. CONCLUSION(S): The current case highlights the safety and feasibility of combined transvaginal and transabdominal oocyte retrieval in patients with an ectopic ovary located in the upper abdomen.
Assuntos
Coristoma/cirurgia , Recuperação de Oócitos/métodos , Ovário , Doenças Peritoneais/cirurgia , Anormalidades Urogenitais/cirurgia , Útero/anormalidades , Abdome/cirurgia , Adulto , Coristoma/complicações , Coristoma/terapia , Feminino , Fertilização in vitro , Humanos , Recém-Nascido , Infertilidade/terapia , Nascido Vivo , Masculino , Doenças Peritoneais/terapia , Gravidez , Teratozoospermia/complicações , Teratozoospermia/terapia , Anormalidades Urogenitais/complicações , Anormalidades Urogenitais/terapia , Útero/cirurgiaRESUMO
OBJECTIVE: To report a case of laparoscopic management of a primary posterior cul-de-sac abdominal ectopic pregnancy (AEP). DESIGN: Video article. SETTING: Academic medical center. PATIENT(S): A 40-year-old G5P3013 woman at approximately 7 weeks of pregnancy was referred to our emergency department because of abnormally rising ß-human chorionic gonadotropin levels. Transvaginal ultrasonography revealed a cystic structure measuring 2.8 × 1.6 ×1.9 cm in the posterior cul-de-sac distinct from the cervix. The mass was noted to have peripheral hypervascularity and a thickened wall. A moderate amount of complex free fluid was noted adjacent to the mass. The patient's baseline ß-human chorionic gonadotropin level and hematocrit were 6,810.7 mIU/mL and 42.4%, respectively. INTERVENTION(S): Laparoscopy for suspected AEP. MAIN OUTCOME MEASURE(S): Laparoscopic excision of a primary AEP. RESULT(S): Diagnostic laparoscopy revealed a normal uterus, normal right ovary, normal left ovary with a corpus luteal cyst, and normal bilateral fallopian tubes without dilatation or hemorrhage. The AEP was noted in the right posterior cul-de-sac and was excised from the underlying peritoneum. The left lateral aspect of the AEP extended into the posterior vaginal wall. The patient was admitted for overnight observation, and her postoperative hematocrit was 35.1%. CONCLUSION(S): AEPs are extremely rare and account for 1% of all ectopic pregnancies. Approximately 90% of AEPs require surgical management. Historically, AEPs were treated with laparotomy because of the high risk of hemorrhage and hemodynamic instability. However, as exemplified by the current case, laparoscopy is a safe and feasible option for surgical management of AEPs.
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Laparoscopia/métodos , Gravidez Abdominal/cirurgia , Adulto , Gonadotropina Coriônica Humana Subunidade beta/sangue , Feminino , Hematócrito , Humanos , Gravidez , Gravidez Abdominal/diagnóstico por imagem , UltrassonografiaRESUMO
We present a case of a tubal ectopic pregnancy (EP) in a patient with an initially undetectable serum ß-human chorionic gonadotropin (ß-hCG) level. A 33-year-old woman in a same-sex relationship underwent timed donor intrauterine insemination. Her serum ß-hCG level was <5 mIU/mL 14 days after the intrauterine insemination. She reported menstrual bleeding 3 days after her negative pregnancy test and returned to the office 10 days later to begin a new treatment cycle. Her serum levels of estradiol, progesterone, and ß-hCG were 119 pg/mL, 6.1 ng/mL and 1157 mIU/mL, respectively. Transvaginal ultrasonography did not show an intrauterine pregnancy. Her ß-hCG level increased to 1420 mIU/mL the next day. She was diagnosed with a pregnancy of unknown location and treated with methotrexate. Her ß-hCG levels continued to increase despite 3 methotrexate doses, necessitating laparoscopy. The diagnostic laparoscopy demonstrated approximately 100 mL of hemoperitoneum in the posterior cul-de-sac with an intact right fallopian tube that was dilated at its distal end by the EP. A total right salpingectomy was performed. Her ß-hCG level was <5 mIU/mL 3 weeks later. The current case supports that although rare, an undetectable serum ß-hCG level does not completely rule out the diagnosis of an EP.
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Gonadotropina Coriônica Humana Subunidade beta/sangue , Gravidez Tubária/diagnóstico , Adulto , Diagnóstico Tardio , Reações Falso-Negativas , Feminino , Fertilização in vitro/efeitos adversos , Hemoperitônio/sangue , Hemoperitônio/diagnóstico , Hemoperitônio/etiologia , Hemoperitônio/cirurgia , Humanos , Inseminação Artificial Heteróloga/efeitos adversos , Laparoscopia/métodos , Metotrexato/uso terapêutico , Gravidez , Testes de Gravidez/efeitos adversos , Gravidez Tubária/sangue , Gravidez Tubária/tratamento farmacológico , Gravidez Tubária/cirurgia , Salpingectomia/métodosRESUMO
OBJECTIVE: To identify the optimal lead follicle size for hCG trigger in clomiphene citrate (CC)-intrauterine insemination (IUI) cycles. DESIGN: Retrospective cohort study. SETTING: University-affiliated center. PATIENT(S): Patients <40 years of age with ovulatory dysfunction or unexplained infertility undergoing their first CC-IUI cycle. INTERVENTION(S): Ovulation induction, hCG trigger, and IUI. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate (CPR) was the primary outcome and was plotted against lead follicle size in increments of 1 mm. Odds ratios with 95% confidence intervals for associations between lead follicle size and CPR were calculated from a multivariable logistic regression model. A receiver operating characteristic (ROC) curve was generated for CPR as a function of lead follicle size. RESULT(S): 1,676 cycles were included. The overall CPR was 13.8% (232/1,676). There was no difference in baseline demographics or ovulation induction parameters of patients who did or did not conceive. The odds of clinical pregnancy were 2.3 and 2.2 times higher with lead follicle sizes of 21.1-22.0 mm and >22.0 mm, respectively, compared with the referent category of 19.1-20.0 mm. Lead follicle size was an independent predictor of CPR, even after accounting for confounders. A lead follicle size of 22.1 mm corresponded to a sensitivity and specificity of 80.1% and 90.4% for clinical pregnancy, respectively, with an area under the ROC curve of 0.89. CONCLUSION(S): hCG administration at a lead follicle size of 21.1-22.0 mm is associated with higher odds of clinical pregnancy in patients undergoing their first CC-IUI cycles for ovulatory dysfunction or unexplained infertility.
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Gonadotropina Coriônica/administração & dosagem , Clomifeno/administração & dosagem , Fármacos para a Fertilidade Feminina/administração & dosagem , Inseminação Artificial/métodos , Folículo Ovariano/fisiologia , Taxa de Gravidez/tendências , Adulto , Tamanho Celular/efeitos dos fármacos , Feminino , Humanos , Infertilidade/diagnóstico por imagem , Infertilidade/terapia , Inseminação Artificial/normas , Masculino , Folículo Ovariano/efeitos dos fármacos , GravidezAssuntos
Transferência Embrionária , Gemelaridade Monozigótica , Adulto , Feminino , Humanos , GravidezAssuntos
Aborto Retido/diagnóstico por imagem , Córion/diagnóstico por imagem , Saco Gestacional/diagnóstico por imagem , Adulto , Transferência Embrionária , Feminino , Fertilização in vitro , Frequência Cardíaca Fetal , Hematoma/diagnóstico por imagem , Humanos , Paridade , Gravidez , Primeiro Trimestre da Gravidez , Ultrassonografia Pré-Natal , Saco Vitelino/diagnóstico por imagemRESUMO
PCOS remains one of the most intriguing endocrine disorders that physicians encounter even though it was first described over 80 years ago. Although the diagnostic criteria, nomenclature, and ideal therapeutic strategies are areas of active and ongoing debate, there is no doubt that we have made tremendous progress in improving the quality of life and reproductive outcomes of women who suffer from this wide-ranging disorder.
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Síndrome do Ovário Policístico/diagnóstico , Síndrome do Ovário Policístico/terapia , Antagonistas de Androgênios/uso terapêutico , Inibidores da Aromatase/uso terapêutico , Biomarcadores/sangue , Clomifeno/uso terapêutico , Anticoncepcionais Orais Combinados/uso terapêutico , Antagonistas de Estrogênios/uso terapêutico , Feminino , Hormônio Foliculoestimulante/sangue , Gonadotropinas/uso terapêutico , Humanos , Hipoglicemiantes/uso terapêutico , Letrozol/uso terapêutico , Hormônio Luteinizante/sangue , Metformina/uso terapêutico , Progestinas/uso terapêutico , Globulina de Ligação a Hormônio Sexual/análise , Testosterona/sangueRESUMO
Infertility is estimated to affect about 10% to 15% of couples. Most cases of infertility have etiologies that can be attributed to tubal factors, ovulatory dysfunction, endometriosis, uterine factor, male factor, or diminished ovarian reserve, while the remainder often do not have a known attributable cause, that is, unexplained infertility. The current manuscript summarizes the contemporary management of unexplained infertility.