Ectopic pregnancy with a contralateral corpus luteum: Case report.

The following report describes the case of an ectopic pregnancy with contralateral corpus luteum after spontaneous conception. The patient was a 33- year-old female (gravida 3, segmentary C sections 3), with positive pregnancy test, and an Intrauterine Device (IUD). The patient was asymptomatic. At vaginal ultrasound, we observed an anteverted uterus of normal shape and size, a 20 x 12 mm intramural myoma and an irregular endometrial thickness of 16.5 mm, with no intrauterine sac. An ectopic pregnancy in the left Fallopian tube and a contralateral corpus luteum were detected, possibly as consequence of ovum pick up through the opposite tube (oocyte transmigration). Further laparoscopic and histopathologic studies confirmed our findings, and the ectopic pregnancy was successfully removed. In conclusion, oocyte transmigration is a common event and should be account when we wish to provide medical advice to patients with a single Fallopian tube trying to conceive. There are real chances for a patient to become pregnant even when only a single tube is present.

Expanded carrier screening in gamete donors of Venezuela.

OBJECTIVE: To discuss the implications of expanded genetic carrier screening for preconception purposes based on our practice. METHODS: One hundred and forty-three potential gamete donors aged 20-32 years old (µ=24, 127 females and 16 males), signed informed consent forms and were selected according to the REDLARA guidelines. Blood or saliva samples were examined by one of these genetic carrier screening methods: Genzyme screening for Cystic Fibrosis (CF), Fragile X and Spinal Muscular Atrophy (SMA); Counsyl Universal panel or Recombine Carrier Map. RESULTS: Genotyping results for all donors were analyzed; 41% (58/143) of donors were identified as carriers for at least one condition. We found a carrier frequency of 1/24 for CF, 1/72 for SMA and 0/120 for Fragile X syndrome. Among the high-impact most prevalent conditions in our study (Carrier Map group) were: 21-Hydroxilase-Deficient Congenital Nonclassical Adrenal Hyperplasia (1/8), Factor V deficiency (1/12), Hemochromatosis: Type 1: HFE Related (1/12), Short Chain Acyl-CoA (1/14) and MTHFR deficiency 1/3 (39%). CONCLUSIONS: The rate of gamete donors identified as carriers of at least one condition was 41%, which supports the offering of expanded carrier screening to our population. Studies in Latin American populations could help customize screening panels. The ART patient population has a unique opportunity to be offered expanded carrier screening and appropriate counseling, to make its best-informed decisions.

Zika virus detected in amniotic fluid and umbilical cord blood in an in vitro fertilization-conceived pregnancy in Venezuela.

OBJECTIVE: To describe the consequences of Zika virus infection at 10 weeks of gestation in an IVF-conceived pregnancy in Venezuela. DESIGN: A case report. SETTING: Private assisted reproduction unit. PATIENT(S): A 36-year-old patient who conceived her first pregnancy through IVF and became infected with Zika virus at 10 weeks' gestation in Venezuela. INTERVENTION(S): In vitro fertilization with fresh ET. Clinical, laboratory, and imaging Zika diagnostic methods. MAIN OUTCOME MEASURE(S): Zika virus detection by real-time polymerase chain reaction (PCR) in maternal plasma, PCR in amniotic fluid and umbilical cord blood. Ultrasonography findings of anatomic abnormalities. RESULT(S): Zika infection was confirmed at 10 weeks' gestation by real-time PCR; ultrasound results appeared normal. At 19 weeks' gestation, an ultrasound revealed biometry on three SDs below the means for all parameters but with no apparent anatomic abnormality. Zika virus was positive in maternal urine and amniotic fluid by PCR at 19 weeks' gestation. Ultrasound at 21 weeks + 4 days of gestation showed fetal cerebellar hypoplasia with ventricular dysmorphia, particularly marked on the left, consistent with microcephaly and ventriculomegaly. Because of the poor prognosis, pregnancy was interrupted at 24 weeks' gestation, in France. The PCR in umbilical cord blood taken in this procedure was positive for Zika virus. CONCLUSION(S): Initial ultrasound findings in pregnancy may not be informative. Only at 21 weeks + 4 days of gestation did an ultrasound reveal fetal microcephaly and ventriculomegaly. Combined clinical, laboratory, and imaging findings provided a complete picture of the severe damage caused by Zika infection.

Echogenic Catheters and Embryo Transfer Standardization.

OBJECTIVE: 1.To describe the standardization process and protocols of the ET method at our center. 2.To compare the performance of non-echogenic catheters with echogenic catheters during ultrasound-guided ET. METHODS: Retrospective analysis of 2630 ET performed at UNIFERTES during 1997-2014, to describe standardization process and to compare the percentage of difficult ET between echogenic and non-echogenic catheters. We tested 17 non-echogenic and three echogenic catheters. RESULTS: Many variables were associated with the ease of ET: informed patients, waiting time for the procedure, speculum use, clinical touch, uterine contractions, cervical mucus removal, presence of blood before or after the procedure, full bladder, ultrasound guidance, uterocervical angle, mock transfer, catheter type (soft or hard, echogenic or non-echogenic, with stylet or not), catheter loading technique, duration of embryo loading (time interval since the embryos were removed from the incubator for loading until the catheter is passed to the physician), transfer procedure (time interval from the catheter was handed to the physician until the embryos were discharged in the uterus), catheter tip placement, retained embryos, bed rest after ET, operator´s proficiency. The diversity of catheters used and the percentage of difficult transfers decrease as the use of echogenic catheters increases. This process is necessary to minimize variation, ensure high quality, safe and evidence-based practice, and improve outcomes. CONCLUSIONS: To standardize the ET method allowed a quicker and easier transfer. The use of echogenic catheters simplified ET procedures guided by abdominal ultrasound.

Vertebral artery dissection as a cause of cervical radiculopathy.

The acute onset of neck pain and arm weakness is most commonly due to cervical radiculopathy or inflammatory brachial plexopathy. Rarely, extracranial vertebral artery dissection may cause radiculopathy in the absence of brainstem ischemia. We describe a case of vertebral artery dissection presenting as cervical radiculopathy in a previously healthy 43-year-old woman who presented with proximal left arm weakness and neck pain aggravated by movement. Cervical magnetic resonance imaging (MRI) and angiography revealed dissection of the left vertebral artery with an intramural hematoma compressing the left C5 and C6 nerve roots. Antiplatelet treatment was commenced, and full power returned after 2 months. Recognition of vertebral artery dissection on cervical MRI as a possible cause of cervical radiculopathy is important to avoid interventions within the intervertebral foramen such as surgery or nerve root sleeve injection. Treatment with antithrombotic agents is important to prevent secondary ischemic events.

Inducción de ovulación en pacientes bajas respondedoras en fecundación in vitro: microdosis de acetato de leuprolide vs priming de estradiol

Objetivo: Comparar los protocolos de microdosis de acetato de leuprolide y priming de estradiol. Métodos: Estudio retrospectivo de 115 pacientes bajas respondedoras (según criterios de Bologna), evaluadas en UNIFERTES desde enero 2010 a diciembre 2012, sometidas a hiperestimulación ovárica controlada según protocolo. La inducción ovárica constó de pauta fija con gonadotropinas (hormona folículo estimulante recombinante 450 UI/día + Gonadotropina menopaúsica humana 150 UI/día); realizando disparo de ovulación con 10.000 UI gonadotropina coriónica humana urinaria al obtener 2 o 3 folículos entre 17-18 mm de diámetro. Se realizó aspiración folicular con aguja bilumen a las 35 horas del disparo, fecundación in vitro en medios secuenciales y transferencia embrionaria al día 3. El soporte de fase lútea constó de progesterona natural micronizada 600 mg/día y valerato de estradiol 4 mg/día. Se realizó prueba de embarazo cuantitativa a los quince días y verificación de embriocardia al mes. Se compara: tasa de cancelación, días de estimulación, número de ovocitos aspirados, tasa de embarazo clínico por transferencia y tasa de aborto. Resultados: Se incluyeron 115 pacientes: 69 al protocolo de microdosis y 46 al de priming de estradiol. No hubo diferencias estadísticas entre ambos protocolos en cuanto a: número de ovocitos aspirados, tasa de embarazo clínico y aborto. Los días de estimulación y la dosis total de gonadotropinas fue mayor con microdosis. Conclusiones: Aunque no hubo diferencias estadísticamente significativas entre ambos protocolos, el de priming de estradiol por tener menos días de estimulación y dosis totales de gonadotropinas menores, implica mayor bienestar de la paciente.

Objective: To compare microdose leuprolide acetate protocols and Estradiol Priming. Methods: Retrospective study of 115 low-responding patients (according to Bologna Criteria), evaluated at UNIFERTES from January 2010 to December 2012, who underwent controlled ovarian hyperstimulation as per Microdose leuprolide acetate protocol or Estradiol Priming Protocols. Ovarian induction consisted of a set standard with gonadotropins, 450UI/day recombinant follicle-stimulating hormone + 150UI/day Human Menopausal Gonadotropin; performing an ovulation trigger shot with 10,000UI urinary human chorionic gonadotropin when obtaining 2 to 3 follicles of 17-18mm diameter. Follicular aspiration is performed with double lumen needle, 35 hours from trigger shot with in vitro fertilization in sequential media, and embryo transfer on day 3. Luteal phase support consisted of 600mg/day micronized natural progesterone and 4mg/day of estradiol valerate. Quantitative pregnancy test was carried out at fifteen days and embryo cardiac activity validation at one month. The following are compared: cancellation rate, stimulation days, number of aspirated oocytes, rate of clinical pregnancy by transfer and abortion rate. Results: 115 patients were included: 69 underwent microdose leuprolide acetate protocol flare and 46 underwent estradiol priming. There were no statistical differences between both protocols with regards to: number of aspirated oocytes, rate of clinical pregnancy by transfer and abortion rate. Stimulation days and therefore, gonadotropins total dosage was greater with microdose leuprolide acetate protocol. Conclusions: Even though there were no significant statistical differences between both protocols, estradiol priming entails greater patient’s wellbeing, since it requires less stimulation days and less gonadotropin total dosages.

Spinal muscular atrophy (SMA) after conception using gametes from anonymous donors: recommendations for the future.

OBJECTIVE: To discuss the diagnosis of spinal muscular atrophy in a child conceived using donor gametes. DESIGN: None. SETTING: None. PATIENT(S): Offspring of gamete donors. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULT(S): A child conceived using gametes from anonymous sperm and ova donors was diagnosed with spinal muscular atrophy type 1. CONCLUSION(S): Gamete donor facilities are not required to perform extensive genetic testing on their donors; however, the well-being of the children conceived through assisted reproductive technologies should be a primary objective of reproductive medicine. The risk for specific medical problems in donor offspring can be significantly reduced by incorporating carrier screening for common, severe disorders such as spinal muscular atrophy into donor screening practices. Future efforts should focus on communicating the limitations of genetic screening to donor gamete recipients and educating them about their reproductive options.

Comparación entre Testsimplets® y Diff-Quik para la evaluación de la morfología espermática / Comparison between Testsimplets® and Diff-Quik to assess sperm morphology

Comparar la evaluación de morfología espermática mediante dos tinciones: Testsimplets® y Diff-Quik y la eficiencia de Testsimplets® y el test de peroxidasa para evaluar leucocitos en semen. Comparamos la morfología espermática de las muestras seminales de 30 pacientes infértiles, evaluada a través de las tinciones Testsimplets® y Diff-Quik. Adicionalmente, en pacientes que presentaron más de 106 de células redondas por mL de semen (n=7), comparamos la evaluación de leucocitos por Testsimplets® y el test de peroxidasa. En el Centro de fertilidad UNIFERTES, en Caracas, Venezuela. No existen diferencias significativas en el porcentaje de espermatozoides morfológicamente normales, siguiendo el criterio estricto de Kruger, entre ambas tinciones. Encontramos diferencias significativas en los porcentajes de los siguientes defectos morfológicos espermáticos, entre tinción: cabeza piriforme, pieza media doblada, irregular o con gota citoplasmática. No se encontraron diferencias significativas en la evaluación de leucocitos en semen mediante Testsimplets® y el test de peroxidasa. Testsimplets® es práctico para ahorrar tiempo y, consecuentemente, mejorar la eficiencia en el tiempo de entrega de resultados. Sin embargo, es considerablemente más costoso que Diff-Quik

To compare sperm morphology by Testsimplets® and Diff-Quik staining. To compare the efficiency of Staining cellular peroxidase and Testsimplets® to assess leukocytes in semen. We compared sperm morphology of 30 infertile patients evaluated by Testsimplets® and Diff-Quik staining. Additionally, in patients with more than 106 round cells per ml semen (n=7), we compared the assessment of leukocytes by Staining cellular peroxidase and Testsimplets®. Fertility clinic UNIFERTES, in Caracas, Venezuela. There was no significant difference in the percentage of morphologically normal sperm, according to Kruger’s strict criteria, between both stains. We found significant differences in the percentages of the following sperm morphological defects between staining: pyriform head, folded middle piece, irregular and presence of cytoplasmic droplets. There was no significant difference in the assessment of leukocytes in semen by Staining cellular peroxidase and Testsimplets®. Testsimplets® is practical for saving time and consequently, improving the efficiency in the delivery time of results. Nonetheless, it is considerably more expensive than Diff-Quik

Infección por Chlamydia trachomatis / Chlamydia trachomatis infection

Determinar la prevalencia de la infección por Chlamydia trachomatis en una población de parejas infértiles. Validar la eficacia del diagnóstico de anticuerpos anti Chlamydia para tratar, prevenir y controlar la infección por C. trachomatis. Justificar la necesidad de implementar el monitoreo de rutina para administrar el tratamiento oportuno de la infección por C. trachomatis. Se determinó la prevalencia de la infección por Chlamydia trachomatis en 4 619 pacientes, 2607 mujeres y 2012 hombres en edades reproductivas, entre 1999 y 2008 por problemas de infertilidad. Se detectaron anticuerpos anti-Chlamydia trachomatis (IgG, IgA e IgM) por SeroELISA (Savyon Diagnostics Ltd.) de 1999 a 2005; desde 2006 hasta 2008 se utilizó el kit InmunoComb II (Orgenics). Centro de fertilidad UNIFERTES, Caracas, Venezuela. Se encontró una prevalencia en mujeres de 25,40 ± 6,26 por ciento; y en los hombres de 31,12 ± 2,88 por ciento. La prevalencia de la infección por C. trachomatis en parejas infértiles es alta y no ha disminuido en los últimos 10 años. Se recomienda implementar en Venezuela un monitoreo de rutina para el diagnóstico de C. trachomatis, incluyendo su determinación en el control ginecológico anual y en las evaluaciones urológicas a hombres jóvenes, a fin de prevenir que la infección pase a ser crónica

To determine the prevalence of Chlamydia trachomatis infection in infertile couples. To evaluate the efficiency of the Chlamydia trachomatis screening programs. To establish the need of implementing the routine early diagnosis and opportune treatment of the infection. Prevalence of Chlamydia trachomatis infection was determined in 4619 patients, 2607 women and 2012 men in reproductive agesbetween 1999 and 2008. Anti-chlamydia and C.trachomatis antobodies (IgG, IgA and IgM) were detected by SeroELISA (Savyon Diagnostics Ltd.) from 1999 to 2005; and by the ImmunoComb II kit (Orgenics) from 2006 to 2008. Fertility clinic UNIFERTES in Caracas, Venezuela. A prevalence of 25,40 ± 6,26 percent was found in women and a prevalence of 31,12 ± 2,88 percent was found in men. Prevalence of the C. trachomatis infection in infertile couples is high and has not decreased over the last 10 years. Implementation of routine screening programs for C. trachomatis detection is recommended, including its assessment in annual gynecological controls, as well as in urologic evaluations in young men, in order to prevent the infection from being chronic

Embarazo triple: un feto normal y dos anencéfalos: a proposito de un caso / Triplet pregnancy: a normal fetus and two anencephalic fetus: a review of the literature is made

Se presenta el primer caso reportado en Venezuela de embarazo triple, bicorial triamniótico, con un feto normal y dos anencefálicos, cuyo diagnóstico se realizó durante el período expulsivo. Se hace revisión de la bibliografía y breves comentarios sobre la patología

Cáncer cervical invasor en la Maternidad Concepción Palacios años 1984-1989 / Invasive cervical cancer in the Maternidad Concepción Palacios years 1984-1989

Se revisaron 77 historias correspondientes a las pacientes con diagnóstico de cáncer invasivo de cuello uterino del Servicio de Ginecología de la Maternidad Concepción Palacios. La mayoría procedían de la región central del país (87 por ciento). El 74 por ciento fueron diagnosticadas en estadios avanzados de la enfermedad (estadio IIB en adelante). El tratamiento consistió fundamentalmente en radioterapia (59 casos). La sobrevida a los 5 años dependió del estado clínico en el que se diagnósticó la enfermedad, siendo menor la sobrevida a partir del estadio IIB. No hubo relación entre la edad con la sobrevida a los 5 años. La causa de muerte en 53,65 por ciento de los casos fue por insuficiencia renal crónica. Se concluye que el diagnóstico de cáncer del cuello uterino se hizo tardíamente, el factor pronóstico más desfavorable fue el compromiso total del parametrio, la sobrevida en 5 años fue baja (46,75 por ciento)

Coriocarcinoma posparto: comunicación de un caso / Postpartum coriocarcinoma: communication of a case

Se presenta el caso de una paciente de 21 años, II gesta, con un coriocarcinoma posparto que cursó con hemorragia vaginal y metástasis pulmonar y epiplón. El tratamiento fue histerectomía con quimioterapia (metotrexate, ácido folínico, actinomicina D). Las metástasis pulmonares permanecieron visibles por largo tiempo en la radialogía de torax pero las cifras de gonadotropinas coriónicas humanas fueron negativas. Actualmente la paciente permanece con criterios de curación

Muy alta tasa de embarazos con transferencia de blastocistos por medios secuenciales: Primeros embarazos en Venezuela / Very high pregnancy rate with blastocyst transfer using sequential medium: first pregnancies in Venezuela

Mejorar las tasas de embarazo clínico y de implantación en fecundación in vitro mediante el cultivo y transferencia de blastocitos. Se controló la estimulación ovárica con ultrasonografía transvaginal y estradiol sérico. Los ovocitos aspirados por vía transvaginal, fueron incubados en medios secuenciales e inseminados con 20.000 espermatozoides móviles por ovocito. La presencia de pronúcleos se evaluó a las 16 horas posinseminación, y se revisó la división celular a intervalos de 24 horas. Al quinto o sexto día posinseminación se realizó la transferencia con embriones que se desarrollaron hasta el estadio de blastocisto. Programa de fecundación in vitro de UNIFERTES, Clínica el Avila. De 37 óvulos, hubo una tasa de fecundación de 64,5 por ciento, de clivaje 100 por ciento, y de estos, hubo 87,5 por ciento blastocitos, se obtuvo una tasa de embarazos clínicos del 100 por ciento y una tasa de implantación del 50 por ciento. Los medios secuenciales soportan bien el desarrollo de los embriones y la formación de blastocistos viables, mejorar la tasa de implantación y embarazo clínico de la fecundación in vitro