Possible risk for cancer among children born following assisted reproductive technology in Israel.

BACKGROUND: Among children conceived by assisted reproductive technology (ART), increased risk of adverse birth outcomes has been observed, including multiple births, preterm births, and congenital malformations. Regarding cancer among ART-conceived children, findings are discrepant. METHODS: This is a historical cohort of 9,042 ART-conceived children and 211,763 spontaneously conceived (SC) children born from 1997 through 2004. The median duration of follow-up was 10.6 years (interquartile range 9.0-12.3) in the ART group and 9.3 years (interquartile range 8.0-10.6) in the SC group. The cohort database was linked with the Israel National Cancer Registry updated until December 31, 2011 using each child's personal identification number. RESULTS: Twenty-one cases of cancer were identified in the ART group (2.2 per 10,000 person-years), as compared to 361 cancer cases in the SC group (1.8 per 10,000 person-years). The relative risk (RR) for overall cancer in the ART group compared to the SC group adjusted for maternal characteristics was 1.18 (95% confidence interval [CI] 0.80-1.75). ART children had a significantly increased risk for specific cancers, although based on small number of cases, including two cases of retinoblastoma (RR 6.18, 95% CI 1.22-31.2), as well as four cases of renal tumors (RR 3.25, 95% CI 1.67-6.32). CONCLUSION: A statistically significant increased risk for two pediatric cancers was found. However, for overall types of cancer the risk estimate was elevated but not statistically significant. Further studies with larger sample size and longer follow-up time are warranted in order to either confirm or refute these findings.

Revealing the uterine blood vessel network via virtual pathology.

BACKGROUND: The distribution of the blood vessel network at any point in time in any body tissue, may provide valuable information with regards to the tissue condition and its angiogenesis functionality. The blood vessel three-dimensional network of the endometrium goes through a process of change over a relatively short period of 4 weeks on average. It is well accepted that this angiogenesis is closely related to the success or failure of the implantation of the embryo Objective and rationale: Our study aims to present a method to follow the three-dimensional evolution of the superficial blood vessel distribution in the endometrium throughout the uterine cycle. METHOD: This method utilizes differences in the observed broadband colors of the blood vessels in order to assess their depth coordinate below the endometrial tissue surface. We implemented the method using microscopic images of fresh, ex-vivo, endometrial samples of different cycle days to obtain the statistical evolution track of the superficial blood vessel population in both human and animal (swine) samples. OUTCOMES: In human samples we observed a systematic and consistent trend in the BV diameter distribution at different tissue depths. We demonstrate that the magnitude of this trend evolves throughout the course of the female cycle. WIDER IMPLICATIONS: This method has the potential to further our understanding of the mechanisms of angiogenesis in tissues other than the endometrium. We propose that this method may also contribute to more precise endometrial dating and may assist in more accurate determination of embryo transfer timing within IVF treatments.

A new method for endometrial dating using computerized virtual pathology.

Endometrial dating (ED) is the process by which the menstrual cycle day is estimated and is an important tool for the evaluation of uterine status. To date, ED methods remain inaccurate and controversial. We demonstrate how the rise of computerized virtual histology changes the state of affairs and introduce a new ED method. We present the results of a clinical trial where magnified images of ex-vivo endometrial tissue samples were captured at different cycle days, together with measurements of serum hormone levels on the same day. Patient testimonies about their cycle day were also collected. Computerized image analysis, followed by statistical representation of the tissue features, allowed mathematical representation of the cycle day. The samples underwent ED histological assessment, which is currently the ED gold standard. We compared dating results from patient reports, serum hormone levels, and histology to establish their concordance level. We then compared histology-based ED with the new method ED in the secretory phase (i.e. post ovulation). The correlation coefficient between the two resulted in an R = 0.89 with a P-value of P < 10-4. The new method, Virtual Pathology Endometrial Dating (VPED), has the benefit of being a real time, in-vivo method that can be repeatedly applied without tissue damage, using a dedicated hysteroscope. One practical use of this method may be the determination of accurate real-time embryo transfer timing in IVF treatments.

Are infertility treatments a potential risk factor for cancer development? Perspective of 30 years of follow-up.

The aim of the present study was to evaluate the possible risk for cancer development in infertile women with over 30 years of follow-up. Cancer development was assessed through linkage with the National Cancer Registry updated to 31 December 2005 in a cohort of 2431 women who were treated for infertility at the Sheba Medical Center in Israel during the period 1964-1974 and contributed more than 84,000 women years of follow-up. Standardized incidence ratios (SIR) were calculated between the observed cancer cases and the expected cancer rates in the general population. The mean age at the end of follow-up was 62.7 years. Eighteen cases of ovarian cancer were observed as compared to 18.1 expected (SIR = 1.0; 95% CI = 0.59-1.57). For breast cancer, 153 cases were observed as compared to 131.9 expected (SIR = 1.16; 95% CI = 0.98-1.36), and for endometrial cancer, 30 cases were observed as compared to 17.8 expected cases (SIR = 1.69; 95% CI = 1.14-2.41). No excess risk associated with exposure to gonadotropins was observed. Infertility was found to be associated with significant increased risk for endometrial cancer and borderline increased risk for breast cancer. Ovarian cancer risk was not found to be elevated. No significant excess risk was associated with treatment with ovulation induction.

Uterine rupture after hysteroscopic resection of uterine septum.

OBJECTIVE: To describe a patient who underwent hysteroscopic resection of a uterine septum for recurrent miscarriage. The subsequent labor caused uterine rupture. DESIGN: Case report. SETTING: Academic medical center. PATIENT(S): A 37-year-old nullipara with three previous miscarriages. INTERVENTION(S): Resection of the septum by cutting diathermy using the operating hysteroscope. MAIN OUTCOME MEASURE(S): Pregnancy and delivery. RESULT(S): The patient had an uneventful pregnancy and spontaneous labor at 41 weeks. Cesarean section was performed because of suspected fetal distress. During cesarean section, the uterus was ruptured transversely along the fundus at the line of the attachment of the septum. CONCLUSION(S): When fetal distress occurs after previous uterine surgery, uterine rupture must be considered as a possible cause and appropriate treatment is necessary.

Increased prevalence of thrombophilia among women with severe ovarian hyperstimulation syndrome.

OBJECTIVE: To determine the prevalence of markers of thrombophilia in women hospitalized for severe OHSS. DESIGN: Prospective study. SETTING: Academic research center. PATIENT(S): Women undergoing induction of ovulation complicated by severe OHSS (n = 20) and women undergoing induction of ovulation without development of severe OHSS (n = 41). INTERVENTION(S): Blood samples to test for markers of thrombophilia were obtained during the luteal phase of the treatment cycle. MAIN OUTCOME MEASURE(S): Blood samples were analyzed for markers of thrombophilia, such as plasma levels of antithrombin, protein S and protein C, antiphospholipid antibodies, the factor V Leiden mutation, and 677T polymorphism in the 5,10 methyltetrahydrofolate reductase (MTHFR 677T) gene. RESULT(S): Seventeen of 20 patients with severe OHSS (85%) and 11 of 41 controls (26.8%) had one or more positive markers of thrombophilia. Of the women with severe OHSS, 6 had a decreased antithrombin level, 8 had decreased levels of protein S, 7 were homozygous for the MTHFR 677T mutation, 1 was heterozygous for the factor V Leiden mutation, and 5 had antiphospholipid antibodies. Eight women with OHSS and no controls had more than one positive marker of thrombophilia. CONCLUSION(S): The prevalence of thrombophilia is increased in women with severe OHSS. These findings suggest that prophylactic screening for this disorder and possible use of heparin prophylaxis for thromboembolic phenomena should be considered in these patients.

Cancer incidence in a cohort of infertile women who underwent in vitro fertilization.

OBJECTIVE: To assess whether ovarian hyperstimulation and IVF increase the risk for cancer. DESIGN: Historical cohort analysis. SETTING; IVF units of two medical centers in Israel. PATIENT(S): Five thousand twenty-six women who underwent IVF between 1981 and 1992. INTERVENTION(S); Cancer incidence rates were determined through linkage to the National Cancer Registry and were compared with expected rates with respect to age, sex, and place of birth. MAIN OUTCOME MEASURE(S): Development of cancer. RESULT(S): Twenty-seven cases of cancer were observed, and 35.6 were expected (standardized incidence ratio, 0.76 [95% CI, 0.50-1.10]). Eleven cases of breast cancer were observed, whereas 15.86 were expected (standardized incidence ratio, 0.69 [95% CI, 0.46-1.66]). One case of ovarian cancer and 1 case of cervical cancer were observed, compared with 1.74 and 1.73 cases expected, respectively. The type of infertility, number of IVF cycles, and treatment outcome did not significantly affect risk for cancer. CONCLUSION(S): In a cohort of women treated with IVF, no excess risk for cancer was noted.

Does preterm cervical dilatation imply imminent labor in multifetal pregnancies?

OBJECTIVE: Women with multifetal pregnancies are at increased risk of preterm labor and delivery compared with singleton pregnancies. Presentation with advanced cervical dilatation of 3-4 cm is generally regarded as being in the midst of the first stage of labor. The purpose of this report is to present our experience in cases of advanced cervical dilatation and arrested preterm labor in multifetal pregnancies. METHODS: This study is a retrospective analysis of threatened preterm deliveries in women with multifetal pregnancies. Fifteen cases with advanced cervical dilatation that remained undelivered for at least 10 days are presented and reviewed. RESULTS: Out of 1219 women presenting with multifetal pregnancies to the high-risk maternity unit, 15 women who presented with advanced cervical dilatation of 3-5 cm and remained undelivered for at least 10 days were identified. Eight women presented with twins and seven with triplets. The mean latency period to delivery was 21.7 days (range 10-43 days). The mean gestational age at diagnosis was 31.3 weeks (range 26.3-35.3 weeks). The mean gestational age at delivery was 34.5 weeks (range 29.5-38.0 weeks). Twelve women delivered vaginally in this group, giving a cesarean section rate of 20%. CONCLUSIONS: In the women presented in this series advanced cervical dilatation did not lead directly to preterm labor and delivery, we believe due to their having a multifetal gestation. It is possible that dilatation of the cervix in these cases is not a result of preterm labor but rather a relative cervical incompetence resulting from overdistention of the uterus in twins or higher-order gestations. This phenomenon may be underdiagnosed because of a tendency to forego frequent digital examinations remote from term without a clear indication. More information is therefore needed on the mechanism of cervical change during multifetal pregnancy.

The effect of adnexal surgery on the ovarian response to stimulation in in vitro fertilization.

OBJECTIVES: The effect of adnexal surgery on ovarian function is a controversial issue of high clinical significance. The purpose of this study was to assess the effect of adnexal surgery on ovarian function. STUDY DESIGN: All patients who underwent adnexal surgery in our department during an 8-year period (all records were obtained from the hospital database between January 1991 and December 1998) were cross-matched with our in vitro fertilization (IVF) database. We compared the baseline hormonal levels and the patients' response to IVF stimulation (assessed by the total amount of gonadotropins, maximal estradiol (E2) levels, number of retrieved and fertilized oocytes). RESULTS: Sixty-four consecutive patients who underwent adnexal surgery were compared with 68 matched controls. Neither of the analyzed parameters were affected by the tubal surgery. CONCLUSIONS: We conclude from our study adnexal surgery is not detrimental to ovarian function.

Laparoscopy versus laparotomy for detorsion and sparing of twisted ischemic adnexa.

BACKGROUND: Torsion of the ovary is an urgent event for fertile women. Until recent years, the common treatment for twisted ischemic ovaries was salpingo-oophorectomy. We have demonstrated in the past that the ovary can be salvaged provided detorsion is performed. We studied the outcome of women undergoing minimal surgery for ischemic ovaries versus the extended procedure including cystectomy in respect of ovarian function and fertility performance. METHODS: We retrospectively studied 102 women who underwent surgery for torsion of the ovary in which the macroscopic appearance of black-bluish ischemic adnexa was encountered during surgery. Detorsion without removal of the adnexa or the ovary was performed by laparoscopy in 67 patients and by laparotomy in 35 patients. Patients' files were reviewed for immediate and late outcomes. Patients were examined postoperatively with vaginal ultrasound for ovarian follicular function. Data concerning patients' further surgeries or in vitro fertilization were retrieved from the charts as well. RESULTS: Febrile morbidity was approximately 15% and 29% in the laparoscopy and laparotomy groups, respectively. Hospital stay was 2.1 +/- 1.2 and 7.4 +/- 1.5 days in the laparoscopy and laparotomy groups, respectively (P<0.001). Ultrasound follow-up was available in 60 of 67 patients who underwent laparoscopy and in 32 of 35 patients treated by laparotomy. Normal-sized ovaries with follicular development were encountered in the detorsed side in 93% and 91%, respectively. Normal macroscopic appearance of the adnexa at subsequent surgeries was reported in 9 of 9 patients in the laparoscopy group and in 4 of 5 patients in the laparotomy group. Four patients from the laparoscopy group and 2 from the laparotomy group underwent subsequent in vitro fertilization. In all 6 patients, oocytes retrieved from the previously detorsed ovary were fertilized. In both groups, none of the patients developed clinical signs of pelvic or systemic thromboembolism. CONCLUSIONS: Torsion of the ischemic adnexa should be treated laparoscopically by detorsion and adnexal sparing.

The development of the fetal thymus: an in utero sonographic evaluation.

OBJECTIVES: To establish a nomogram for fetal thymus size during gestation. METHODS: The study is a prospective, cross sectional evaluation of 403 male and female fetuses between 14 and 38 weeks of normal singleton pregnancies. Measurements of fetal thymus size were performed by high resolution transvaginal ultrasonography between 14 and 17 weeks' gestation, and by transabdominal ultrasonography after 18 weeks' gestation. RESULTS: Adequate thymus size measurements were obtained in all 403 fetuses. Thymus size as a function of gestational age was expressed by the regression equation: (square root) thymus size (mm)= -39.39+4.41 x gestational age (weeks). The correlation coefficient, r=0.965, was found to be highly statistically significant (p<0.0001). The normal mean and the 90% prediction limits were defined. CONCLUSION: The present data offer the normal range of fetal thymus size from early stages of gestation that may allow intrauterine assessment of its development. It may be helpful in the prenatal diagnosis of thymic pathologies.

A simple, inexpensive method of specimen removal at laparoscopy.

After completing operative laparoscopy, it is often necessary to enlarge a 5-mm port to 10 or 12 mm for tissue removal. This may increase the risk of vessel injury and herniation, and has obvious cosmetic drawbacks. A simple, cost-effective technique for tissue removal does not require enlarging the 5-mm port. A long, firm thread is sutured to a sterile plastic bag. When tissue removal is required, the optic telescope is removed and the bag is blindly introduced through the available optical 11- or 12-mm cannula. The telescope is reintroduced, keeping the end of the thread outside the cannula sleeve. The specimen is placed in the bag and the bag is removed by pulling the suture through the optical cannula after removing the telescope. This technique was performed successfully in over 300 patients, with no difficulty or complication either during or after surgery. The device is inexpensive and takes 2 minutes to assemble.

Familial partial 17,20-desmolase and 17alpha-hydroxylase deficiency presenting as infertility.

PURPOSE: Females with 17alpha-hydroxylase/17,20-desmolase deficiency normally present with amenorrhea, sexual infantilism, hypertension, and hypokalemia. We report on a new clinical presentation of this combined enzymatic defect. METHODS: Four Jewish women from two unrelated families presented with primary infertility. All patients exhibited a normal phenotype, blood pressure, and serum potassium levels with abnormally high follicular phase serum progesterone and low E2 levels. In order to characterize the underlying defect, the following steps were undertaken: 1) ovarian suppression by GnRH agonist, 2) adrenal suppression by dexamethasone, 3) ovarian stimulation by gonadotropins, 4) adrenal stimulation by ACTH, 5) hormonal assessment of follicular fluid aspirates, and 6) assessment of in vitro E2 production by luteinized granulosa cells. RESULTS: The clinical characteristics and endocrine testing results support the diagnosis of a partial deficiency in 17alpha-hydroxylase/17,20-desmolase activities, shared by the adrenal gland and the ovaries CONCLUSIONS: Female infertility can be the first and sole clinical manifestation of this enzymatic defect. Its exact nature and prevalence remain to be determined.

Factors influencing the obstetric and perinatal outcome after oocyte donation.

BACKGROUND: We evaluated interactions between perinatal outcome after oocyte donation and various maternal factors. METHODS: The study included 134 parturients after oocyte donation. Data were collected from medical files and personal interviews. Stepwise logistic regression analyses were used to evaluate associations between perinatal outcomes and selected maternal variables. RESULTS: Fifty percent of the women were >43 years old, 30.6% were >45 years and 67.9% were nulliparous. The rates of pregnancy induced hypertension (PIH), gestational diabetes and first and second trimester vaginal bleeding (STB) were 27.6, 23.9, 43.3 and 6% respectively, while 72% had Caesarean deliveries. The rates of preterm (PD), low birth weight (LBW), small for gestational age (SGA) deliveries and major malformations were respectively 14.9, 14.9, 7.6 and 2.2%. Using a logistic regression, PD was significantly associated with PIH, STB and maternal smoking. LBW deliveries were significantly associated with PIH, STB, nulliparity and maternal smoking. SGA babies were significantly associated with PIH. These perinatal outcomes were not associated with advanced maternal age or ovarian failure. CONCLUSIONS: There is a high risk of obstetric complications in singleton oocyte donation pregnancies, but the perinatal outcomes are favourable. Patients should be counselled about these risks and monitored for these complications during pregnancy.

Diagnosis and treatment of heterotopic pregnancy compared with ectopic pregnancy.

STUDY OBJECTIVE: To compare the diagnosis and management of ectopic (EP) and heterotopic pregnancies (HP). DESIGN: Retrospective comparative study (Canadian Task Force classification II-2). SETTING: University tertiary referral center for endoscopic surgery. PATIENTS: Twelve women with HP and 210 women with laparoscopically confirmed EP. INTERVENTION: Laparoscopic treatment. MEASUREMENTS AND MAIN RESULTS: Among the 12 women with HP, all but 1 had received ovulation induction, 10 underwent in vitro fertilization-embryo transfer, and 1 conceived with clomiphen citrate. In the EP group 33 patients (15.7%) conceived spontaneously (p <0.05). Six women (50%) with HP had had previous pelvic surgery and three had a history of EP and salpingectomy. Four patients (33.4%) with HP and 29 (13.8%) with EP suffered from hypovolemic shock and required blood transfusion (p <0.05). Three of these four women with HP experienced physician and patient delays before admission. The sonographic diagnosis was correct in all women with HP and in 94.3% of women with EP. The median gestational age at diagnosis was 7.5 and 7.2 weeks for HP and EP, respectively. Six (50%) women with HP had evidence of fetal pulse in the ectopic gestation compared with 17 (8.1%) with EP (p <0.05). In addition, 66.7% and 24.7%, respectively, had ruptured tube (p <0.05). Mean +/- SD hemoperitoneum was 833.4 +/- 777 and 305 +/- 121 ml, respectively (p <0.05). Conversion to laparotomy was required in one (8.3%) and eight (3.8%) women, respectively (p <0.05). No major operative or postoperative maternal complications occurred in either group. Two women with HP had miscarriages, two have a continuing pregnancy, and eight delivered healthy newborns. CONCLUSION: Women with HP are at significantly greater risk for hypovolemic shock and requiring blood transfusion than those with EP. The diagnosis of EP in cases of HP is difficult due to the presence of an intrauterine gestational sac and hyperstimulated ovaries. A greater level of suspicion may allow early laparoscopic intervention before life-threatening intraabdominal bleeding has occurred.

Cervical Shirodkar cerclage may be the treatment modality of choice for cervical pregnancy.

BACKGROUND: Our objective was to evaluate the use of cervical suture in cervical pregnancy. METHODS AND RESULTS: All cases of cervical pregnancy diagnosed and treated in the gynaecological department at the Sheba Medical Center between 1994-2000 were included in the study. Eight such cases were diagnosed. The first four cases were treated medically. The last four cases (the study group) of cervical pregnancy, including one case of heterotopic pregnancy, were treated successfully with placement of Shirodkar cerclage. CONCLUSION: Cervical cerclage may be considered as the treatment of choice in cases of cervical pregnancies. It may be the only therapy in cases of heterotopic pregnancies (intrauterine and cervical pregnancy).

The early development of the fetal kidney-an in utero sonographic evaluation between 13 and 22 weeks' gestation.

OBJECTIVES: To establish a nomogram for early fetal kidney development during early gestation. METHODS: The study is a prospective, cross-sectional evaluation of 275 male and female fetuses between 13 and 22 weeks in normal singleton pregnancies. Measurements of fetal kidney length were performed by high resolution transvaginal ultrasonography between 14 and 17 weeks' gestation, and by transabdominal ultrasonography beyond 18 weeks' gestation. RESULTS: Adequate kidney length measurements were obtained in all 275 normal fetuses as well as in six fetuses with urinary tract anomalies. Kidney length as a function of gestational age was expressed by the regression equation: (square root) kidney length (mm) = -11.66 + 1.52 x gestational age (weeks). The correlation coefficient, r = 0.983 was found to be highly statistically significant (p < 0.0001). The normal mean and the 90% prediction limits were defined. Four cases with single kidney and two cases with posterior urethral valve had kidney length above the 95% upper limit. CONCLUSION: The present data offer a normal range of fetal kidney length from early stages of gestation that may allow intrauterine assessment of its development. It may also be helpful in the early prenatal diagnosis of renal abnormalities.

Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function.

BACKGROUND: Recently detorsion has replaced salpingo-oophorectomy as treatment for the twisted ischaemic adnexa. This paper asssess whether the ovary resumes normal function after preservation by detorsion. METHODS: The results of detorsion performed between January 1988 and December 2001 were retrospectively analysed. Post-operative complications and subsequent ovarian function were assessed including: ultrasound monitoring of follicular development, adnexal appearance during subsequent surgery, and the outcome of IVF. RESULTS: A total of 102 detorsions were performed; 67 by laparoscopy, 35 by laparotomy. No patient developed thromboembolism. Post-operative fever occurred in 15% of patients after laparoscopy and 29% after laparotomy (P < 0.01). Patients were hospitalized for a mean (+/- SD) of 2.1 +/- 1.2 and 7.4 +/- 1.5 days after laparoscopy and laparotomy respectively (P < 0.001). Ultrasound showed normal follicular development in 93 and 91% of patients after detorsion by laparoscopy and laparotomy respectively. At subsequent surgery, the adnexa appeared normal in nine out of nine patients after laparoscopy and in four out of five patients after laparotomy. Four patients of the laparoscopy group and two patients of the laparotomy group underwent subsequent IVF. In all six patients oocytes retrieved from the previously ischaemic ovary were fertilized. CONCLUSIONS: Detorsion with adnexal sparing is the treatment of choice for twisted ischaemic adnexa, and preferably performed by laparoscopy.

Management and outcome of pregnancy in women with thrombophylic disorders and past cerebrovascular events.

OBJECTIVE: To evaluate the maternal and fetal outcome in a cohort of women undergoing a subsequent pregnancy after a previous cerebrovascular event in the presence of thrombophilia. PATIENTS: Fifteen pregnancies were followed up in 12 women with past cerebrovascular events and thrombophilic disorders. The cerebrovascular events occurred during a previous pregnancy in five patients. Six patients had a bad obstetric history including intrauterine fetal death in four cases, early onset of severe preeclampsia in two cases and one infant that was small for gestational age. THE THROMBOPHILIC DISORDERS INCLUDED: anti-phospholipid syndrome, protein C, S or antithrombin III deficiencies, mutations of the methyltetrahydrofolate reductase (MTHFR). All patients received prophylactic treatment with low molecular weight heparin and low dose aspirin. RESULTS: Thromboembolic complications occurred in four pregnancies. Postpartum complications occurred in one patient; deep vein thrombosis and pulmonary emboli after stopping anticoagulation treatment. No patient had long-term neurologic damage. All pregnancies except one resulted in live births. (mean gestational age at delivery 36 +/- 3. 7 weeks, mean birth weight 2656 +/- 811 g). The one remaining pregnancy was electively terminated. There was one neonatal death due to the complications of severe prematurity in a woman with severe HELLP syndrome. CONCLUSION: This preliminary data suggests that women with a history of cerebrovascular events and thrombophilic disorders receiving prophylactic treatment, have a relatively favorable pregnancy outcome; however, they remain at significant risk during pregnancy. Further studies are necessary to determine the optimal prophylactic treatment.