Ultra-short metformin pretreatment for clomiphene citrate-resistant polycystic ovary syndrome.

OBJECTIVE: To evaluate the effect of ultra-short (12 days) metformin pretreatment in clomiphene-citrate (CC) resistant polycystic ovary syndrome (PCOS). METHOD: Eighty women with CC-resistant PCOS were randomly allocated to metformin pretreatment or usual treatment. Forty women received 1500 mg metformin daily for 12 days, followed by clomiphene 150 mg daily for 5 days along with metformin. Forty women (control group) received the same dose of clomiphene but no metformin pretreatment. RESULTS: In the metformin group, 17 (42.5%) women ovulated, and 6 (15%) conceived. In the control group, 5 (12.5%) women ovulated but none conceived. Compared with the control group, the metformin group had significantly higher ovulation (P = 0.03) and pregnancy rates (P = 0.026). CONCLUSION: Twelve days of metformin pretreatment improves ovulation and pregnancy rates in women with CC-resistant PCOS.

A frame shift mutation in the DNA-binding domain of the androgen receptor gene associated with complete androgen insensitivity, persistent müllerian structures, and germ cell tumors in dysgenetic gonads.

OBJECTIVE: To describe the molecular, cytogenetic, immunohistochemical, and endocrinologic characteristics of a young 46,XY female with persistent müllerian structures and germ cell tumors in dysgenetic gonads. DESIGN: Descriptive case study. SETTING: Mackay Memorial Hospital and National Yang-Ming University, Taipei, Taiwan. PATIENT(S): A 22-year-old 46,XY female with persistent müllerian structures, a low level of serum testosterone, and no apparent adnexal masses. INTERVENTION(S): Laparoscopic removal of the dysgenetic gonads. MAIN OUTCOME MEASURE(S): Detection of an androgen receptor gene mutation by a semiautomated DNA sequencer, of the chromosomal complement by cytogenetic examination, of placental alkaline phosphatase activity by immunohistochemical analysis, and of neoplasms in dysgenetic gonads by histologic studies. RESULT(S): A unilateral gonadoblastoma and a contralateral gonadoblastoma associated with a dysgerminoma were found in the excised gonads. The tumors had a 46,XY complement. Placental alkaline phosphatase was present in the tumor cells. A frameshift mutation in the DNA-binding domain of the androgen receptor gene was detected in the patient's blood and the tumor tissues. A five-nucleotide "AGGAA" deletion at codons 608 and 609 of the androgen receptor gene resulted in a missing arginine and lysine as well as a frameshift that introduced a stop codon 12 amino acid downstream from the mutation. CONCLUSION(S): Molecular genetic analysis of the androgen receptor gene aids in the rapid diagnosis of complete androgen insensitivity irrespective of atypical clinical phenotypes and endocrinologic parameters.

Reproducibility of the revised American Fertility Society classification of endometriosis using laparoscopy or laparotomy.

OBJECTIVE: To assess the discrepancy between laparoscopic and laparotomic scoring methods using the revised American Fertility Society (AFS) classification of endometriosis. METHOD: In this prospective study, 84 patients with endometriosis were scored twice (laparoscopically and laparotomically) by the same subspecialty-certified reproductive endocrinologist. The magnitude of inter-method variability was reported quantitatively by the S.D. of the differences in scores between the pairs. The differences in the mean endometriosis scores between the two methods were assessed by the paired Student's t-test. P < 0.05 was considered as statistically significant. Discrepancy between the two methods in the staging of endometriosis patients was presented by kappa measure of agreement. RESULT: There was considerable variability in the scores between the two scoring methods by the same observer. Among individual components of the scoring system, the greatest variability occurred in the ovarian endometriosis and cul-de-sac obliteration subscores, with the least variability observed for peritoneum endometriosis. The inter-method variation in score was sufficient to alter the endometriosis staging in 34.5% of patients, including a difference of two stages in 3.6% of patients. The kappa coefficient was 0.49, indicating fair-to-good agreement between the two scoring methods. CONCLUSION: Inter-method variability between laparoscopic and laparotomic scoring methods was high for ovarian endometriosis subscore using the revised AFS classification of endometriosis. Agreement in endometriosis staging between the two methods was fair to good.

Ratio of Wnt3a to BMP4 doses is critical to their synergistic effects on proliferation of differentiating mouse embryonic stem cells.

OBJECTIVES: To investigate potential interactions between bone morphogenetic protein (BMP) and Wnt signalling on differentiating mouse embryonic stem cells (mESC). MATERIALS AND METHODS: Mouse embryonic stem cells were cultured with differing combinations of Wnt3a, BMP4 and inhibitors of Wnt, BMP, PI-3K (phosphoinositide 3-kinase), p38, ERK1/2 (extracellular signal-regulated kinase 1/2) and JNK (c-Jun N-terminal kinase) pathways. RESULTS: We found that Wnt3a synergized with BMP4 to promote mESC proliferation. Furthermore, the relative ratio of Wnt3a to BMP4 doses was critical to their synergistic effects, which could be abolished by using Dkk-1, noggin or the inhibitors of PI-3K, p38, ERK1/2 and JNK pathways. We also demonstrated that combination of Wnt3a and BMP4 could suppress ectodermal differentiation of mESCs. Moreover, inhibitors of PI-3K, p38, ERK1/2 and JNK pathways could negate this effect. CONCLUSION: Relative ratio of Wnt3a to BMP4 doses is critical to their synergistic effect on differentiating mESC proliferation, which may work through PI-3K, p38, ERK1/2 and JNK pathways.

A comparison of the effects of different degrees of zona pellucida damage followed by cryopreservation on the postthaw development of mouse embryos.

PURPOSE: The totally intact zona pellucida is not essential for the development of embryos. It is still unclear how much effect the degree of damages to the zona pellucida will have on the developmental potential of postthaw embryos after cryopreservation. We compared the developmental potential of cryopreserved mouse embryos after induction of two degrees of mechanical damage to the zonae pellucidae by micromanipulation. METHODS: In experiment I, the development of 124 cryopreserved ICR mouse embryos to the blastocyst stage after zona pellucida penetration of two-cell embryos as in the procedures of subzonal sperm insertion (SUZI) was compared with the development of zona-intact cryopreserved embryos. In experiment II, the zonae pellucidae of 93 two-cell mouse embryos were dissected as in the procedures of partial zonal dissection (PZD), following which the embryos were frozen. This postthaw development was also compared with that of zona-intact two-cell cryopreserved embryos. All the embryos were thawed and cultured to the blastocyst stage. Additional controls were provided by culturing zona-intact and zona-penetrated or zona-dissected embryos without cryopreservation. RESULTS: The development of unfrozen mouse embryos was not affected by either zona penetration (P = 0.433) or zona dissection (P = 0.659). The developmental potential of cryopreserved mouse embryos was significantly affected after zona dissection (blastocyst rate, 31% ZD vs 72%, control; P < 0.001) but not after zona penetration (blastocyst rate, 59% ZP vs 64% control; P = 0.441). CONCLUSIONS: The quality of cryopreserved embryos was affected by a large hole on the zona pellucida created by zona dissection but not by simple zona penetration.

Congenital complete atrioventricular block--two cases report.

We encountered two cases of congenital complete atrioventricular block out of 23,400 deliveries during the past 3 years. Two-dimensional and M-mode fetal echocardiography revealed complete atrioventricular block without structural abnormality. Anti-Ro (SS-A) antibodies were present in both the mother and infant of these two cases. The ventricular rates of these two infants were 31 and 80 beats/min respectively. Pacemaker implantation was performed for the first infant.

The residual ovary syndrome.

An analysis of 35 cases of the residual ovary syndrome was performed retrospectively. In sixty percent of the patients, the residual ovary syndrome occurred within 5 years after the hysterectomy. The most common symptom of these patients was chronic pelvic pain. Extensive pelvic adhesions were the typical operative findings, while follicular cysts and corpus luteum hematoma were the common pathological findings of the residual ovaries. However, malignant changes were found in 4 cases. In this study, the probable incidence of the residual ovary syndrome was 2.3% which is compatible with other reports and the probable incidence of malignant change among patients with the preserved ovaries was 0.26% which is about the same as the general population. Because the conservation of normal ovarian function has great importance to the premenstrual woman, we suggest that the grossly normal ovaries should be conserved on premenstrual woman but should always be removed on postmenopausal woman when hysterectomy is done.

Embryonic dormancy phenomenon in obstructed healthy mouse fallopian tubes.

PURPOSE: A mouse model of unilateral oviductal obstruction was designed to study whether healthy oviducts can support embryo development in an advanced stage toward blastocyst hatching and implantation when the embryos in the contralateral side normally move into the uterine cavity. METHODS: The oviducts of 80 female ICR mice (aged 5-8 weeks) were ligated unilaterally 12-40 hr postcoitus. The ligated oviducts were isolated from day 4 to 19.5 postcoitus. Embryos within the ligated oviducts were then flushed out to record the developmental stage and compared with the conceptuses in the contralateral uterine horns with unligated oviducts. Embryos recovered from ligated oviducts were then cultured in vitro to observe their potential for further development. RESULTS: In 33 mice, 53.4% (163/305) and 86.1% (241/280) of the morphologically normal blastocysts had hatched from the zona pellucida within the obstructed tube and contralateral uterine horns, respectively, on the 5th day postcoitus. The data demonstrated that the hatching process could take place within the obstructed fallopian tube, but the timing was delayed. From 5.5 to 19.5 days postcoitus, a total of 362 implanted embryos were obtained in unligated control uterine horns, but none of the 404 embryos in the artificially obstructed oviducts were implanted. The embryos within the ligated tubes were dormant in the hatched blastocyst stage as demonstrated by their ability to continue growing (98.2%) when removed from the oviduct to an in vitro environment. CONCLUSIONS: In this study, we demonstrate that mouse embryos can hatch, although delayed, in obstructed healthy oviducts. Tubal pregnancy is not likely to happen in artificially obstructed healthy mouse fallopian tubes, since all the viable embryos were dormant at the hatched blastocyst stage.

Separating X-bearing human spermatozoa through a discontinuous Percoll density gradient proved to be inefficient by double-label fluorescent in situ hybridization.

PURPOSE: Double-label fluorescence in situ hybridization (FISH) was used to evaluate the efficiency of separating X- and Y-chromosome-bearing spermatozoa through 12-step discontinuous Percoll gradients. METHODS: Liquefied normal semen samples from 10 healthy donors were overlaid onto 25% Percoll and centrifuged. Parts of the sperm pellet were saved as control, while the remaining portion was separated by 12-step Percoll gradient. After centrifugation, the spermatozoa in the 80% Percoll layer were collected. The X:Y ratio of the control and separated spermatozoa was verified by double-label FISH (CEP SOX/SGY probes) and scored blindly by one observer. Differences in the X:Y ratios between matched groups were analyzed by paired t tests. RESULTS: The overall average labeling efficiency was 99.2%. A significant enrichment (P = 0.02) of X-bearing spermatozoa was obtained in Percoll separated fractions (mean X:Y ratio = 52.2:46.4) compared with the control group (X:Y ratio = 49.5:48.4). Discontinuous Percoll gradients also decreased the proportion of aneuploid spermatozoa (from 1.0 to 0.8%), but the differences were nonsignificant. CONCLUSIONS: Discontinuous Percoll separation did increase the X:Y ratio significantly, but the enrichment of X-bearing spermatozoa is insufficient for clinical use in preconceptional sex selection.

Development of hatching blastocysts from immature human oocytes following in-vitro maturation and fertilization using a co-culture system.

Recently, in-vitro maturation (IVM) of immature human oocytes recovered from non-stimulated follicles has been applied in the treatment of infertility. However, in previous reports, very few embryos cultured in conventional medium have reached the expanded blastocyst stage following in-vitro maturation and fertilization (IVM/IVF). The objective of this study was to investigate whether the developmental competence of human embryos following IVM/IVF could be enhanced by the use of a human ampullary cell co-culture system. Immature human oocytes were aspirated from small follicles at Caesarean section and then cultured in medium containing human menopausal gonadotrophin for 36 to 48 h, followed by insemination. Zygotes were randomly cultured either in conventional culture medium alone or in the co-culture system. Of 48 embryos cultured in conventional medium alone, all arrested at the 2-16-cell stage on day 3 after insemination. Of 46 embryos cultured in the co-culture system, 26 embryos (56.5%) arrested at the 2-16-cell stage. Six embryos (13%) developed to the morula stage. Fourteen embryos (30.4%) developed to expanded blastocysts and two blastocysts were hatching on day 7 after insemination. We conclude that co-culture significantly enhances the development of blastocysts in embryos resulting from IVM/IVF.

The effects of brief gamete co-incubation in human in vitro fertilization.

PURPOSE: To investigate whether very short exposure of mature oocytes to sperm in vitro may affect the fertilization rates, embryo cleavage rates, and embryo quality between sibling oocytes in the same patient. METHODS: Sibling oocytes of the same patient from 23 oocyte collection cycles were randomly allocated to the study group, with a 1-hr or 3-hr sperm-oocyte incubation, or the control group with the standard overnight gamete co-incubation. The fertilization rates, cleavage rates, and subsequent embryo quality were evaluated. RESULTS: Our results showed no statistically significant differences in fertilization rates, embryo cleavage rates, and quality of the embryos between the study group and the control group. CONCLUSIONS: Since the present study showed that long exposure of the oocyte to sperm has no advantage over short exposure, we prefer shortening the oocyte-sperm incubation period for reducing the negative effect induced by nonphysiologically high concentrations of spermatozoa.

Mini-catheter used for bladder drainage following stress-incontinence surgery and the factors relating to drainage failure.

OBJECTIVES: To determine the most effective length for the mini-catheter and to discuss factors relating to drainage failure. METHODS: Prospective study of a No. 8 silastic feeding tube for bladder drainage omits the necessity of additional catheterization for measuring residual urine. This two-part study in which 146 patients took part, first, determined the suitable length for insertions for the perforated portion and the imperforated portion; then, gauged the effectiveness of the mini-catheter with desired proportions. RESULTS: Drainage is better when the imperforated portion is at least 5 cm in length (p = 0.0129). The length of the perforated portion, on the other hand, has less impact of the resultant drainage provided that its length does not exceed 5 cm. Beyond this length, an obstruction often occurs. There were 2 obstructions (1.3%) induced by blood clot as well as 9 patients (5.8%) who suffered from one, or more, complications attributed to the mini-catheter for reasons other than the length of insertion. CONCLUSIONS: When care is taken in creating a mini-catheter of the proper proportions, it offers many advantages and very few complications to gynecologists and patients alike.

Clinical and perinatal sonographic features of congenital adrenal cystic neuroblastoma: a case report with review of the literature.

Cystic formation in association with adrenal neuroblastoma may be related to hemorrhage and necrosis of the tumor. We present an unusual case of congenital cystic fetal neuroblastoma of the right adrenal gland detected at 37 weeks' gestation which evolved into a complex echogenic mass 6 weeks after birth. Surgical exploration revealed a 3.5 x 3 x 3 cm right complex adrenal tumor which was resected. The infant did well 10 weeks after tumor resection. Typically adrenal hemorrhage may appear sonographically to be entirely echogenic, of mixed echogenicity, or anechoic when first imaged. Gradually, the texture of the hematoma will evolve and become more cystic and echolucent on follow-up ultrasound examinations. In contrast, our case of congenital adrenal cystic neuroblastoma became more complex after resolution of the hemorrhagic cyst. This case suggests that adrenal hemorrhagic and adrenal cystic neuroblastoma with a hemorrhagic cyst have different sonographic appearances. We suggest that additional imaging and surgical intervention should be considered whenever a cystic suprarenal mass becomes more complex after resolution and demonstrates no significant decrease in size in postnatal examinations.