Selection of patients before and after anticancer treatment for ovarian cryopreservation.

BACKGROUND: Although ovarian cryopreservation in patients with cancer should ideally be performed before the initiation of therapy, cryopreservation from such patients often becomes an option only later. The justification for the procedure needs to be elucidated. METHODS: Eighteen cancer patients before chemotherapy and 23 others after chemotherapy participated in the study. Freshly dissected ovarian samples were prepared for light microscopy to demonstrate follicular numbers and apoptosis, transmission electron microscopy to enhance intracellular changes, and staining with fluorescent markers (calcein AM, rhodamin 123 and ethidium homodimer) to test for viability. RESULTS: High numbers of preantral follicles were detected in ovaries of patients < or =20 years. No antral follicles were detected. All the follicles were viable and not apoptotic. Deterioration in follicular quality was observed after chemotherapy, manifested mainly as an increase in abnormal granulosa cell nuclei (P < 0.05-0.0001) and in oocyte vacuolization (P < 0.0001). CONCLUSIONS: Our study stresses the importance of prechemotherapy ovarian cryopreservation. However, the large number of viable, non-apoptotic follicles in ovaries of younger patients (age < or = 20 years) indicates that ovarian cryopreservation might be considered after treatment in this age group. Further studies of ovarian samples from women aged 20-30 years are needed to determine the exact age margin wherein postchemotherapy ovarian cryopreservation can be suggested.

Parameters affecting successful transplantation of frozen-thawed human fetal ovaries into immunodeficient mice.

OBJECTIVE: To compare the development and survival of human fetal follicles frozen-thawed with dimethylsulfoxide (DMSO) and propandiol (PROH) in immunodeficient mice, to study the effects of host treatment with FSH, and to compare kidney and subcutaneous transplantation. DESIGN: Controlled histologic study. SETTING: Major tertiary care and referral academic center.Twenty-one women undergoing second-trimester pregnancy termination. Microscopic morphometric analysis and immunocytochemistry for proliferating-cell nuclear antigen in human fetal ovaries grafted into immunodeficient mice. RESULTS: Renal grafts that were frozen-thawed with DMSO rather than PROH survived better in the hosts (79.6% compared with 58.8%), but significantly more follicles were identified in grafts frozen-thawed with PROH (P<.001). Follicular development was observed only in FSH-treated hosts, and follicular survival and development was better in the kidney than the subcutaneous site. CONCLUSION(S): This is the first report showing development of human fetal follicles in immunodeficient mice. Freezing-thawing with PROH seems to support development and survival better than with DMSO. The kidney is a better transplantation site than the subcutaneous site, probably because of its superior vascularization. Administration of FSH to the host is essential for follicular development. Follicular development and growth was better in ovarian grafts from older fetuses, as they contained more formed follicles.

Lost levonorgestrel IUD: diagnosis and therapy.

A lost intrauterine device (IUD) is an uncommon event. Recently, a new levonorgestrel-releasing intrauterine system was introduced. In view of several cases of an unusual diagnostic discrepancy in the location of a lost levonorgestrel-releasing IUD in our department, we sought to determine if the extrauterine location of lost levonorgestrel-releasing IUDs differs from that of lost copper IUDs. The medical files of all patients with a diagnosis of lost IUD who were admitted to Rabin Medical Center from 2000 to 2003 were reviewed. Fourteen women were identified, 9 with levonorgestrel-releasing IUDs and 5 with copper IUDs. In six of the nine cases of a lost levonorgestrel-releasing IUD, there was a clear discrepancy between the presumed location of the device by diagnostic evaluation and its actual location on surgical extraction. All six devices were embedded in the omentum; four were located in the upper abdomen. No such discrepancies were noted for the copper IUDs (0 vs. 66%, p < 0.05). No significant difference in peritoneal adhesions was noted between the groups (55% vs. 66%, respectively, p = 0.095). It is concluded that lost levonorgestrel-releasing IUDs are associated with a higher rate of localization errors by clinical evaluation than copper IUDs. Lost levonorgestrel-releasing IUDs might be found in the mid-upper abdomen, embedded in omentum tissue, and this area should be explored first during laparoscopy.

[Complications of surgery for stress incontinence in women].

For some women with stress incontinence, surgery is the only effective treatment. More than 100 different operations are reported to cure stress incontinence. The reason for this variety is the fact that none of the operations is entirely satisfactory. This review aims to highlight the complications of surgery for stress incontinence in women.

Outcome, complications and future fertility in women treated with uterine artery embolization and methotrexate for non-tubal ectopic pregnancy.

OBJECTIVE: To determine the effectiveness and safety of uterine artery methotrexate (MTX) infusion and embolization combined with systemic MTX for treatment of non-tubal ectopic pregnancy. STUDY DESIGN: We retrospectively reviewed the electronic files of all women admitted to a single tertiary, university-affiliated medical center with a diagnosis of non-tubal (cervical, interstitial or cesarean section scar) ectopic pregnancy, who were treated by a combination of uterine artery MTX infusion and embolization and systemic MTX between January 2001 and March 2014. The treatment protocol included a total of 4 MTX injections in doses of 1 mg/kg/day every other day (days 1, 3, 5, 7 of the protocol) alternating with folinic acid 0.1 mg/kg (days 2, 4, 6, 8). The first or second MTX dose was administered by transcatheter intra-arterial injection during the embolization procedure just before injecting Gelfoam for bilateral uterine artery occlusion, and the remaining doses were given intramuscularly. RESULTS: During the study period, 25 women underwent uterine artery infusion and embolization combined with systemic MTX treatment for non-tubal ectopic pregnancy. Ten of the pregnancies were cervical, 9 were interstitial, and 6 were cesarean scar pregnancies. Mean gestational age and beta-human chorionic gonadotropin (ß-HCG) level at admission were 68.6±12.9 days and 14,179 (range 436-61596) IU/L, respectively. Treatment was successful in 24 patients (96%) with mean ß-HCG resolution time of 52.6 (6-147) days. Mild immediate side effects were reported including 8 cases (32%) of abdominal discomfort, 3 cases (12%) of groin or leg pain and 3 cases (12%) of puncture-site local skin infection. No serious immediate side effects such as internal vascular bleeding, sepsis or early liver or renal failure were observed. Among 12 women who stated that they tried to conceive and were more than a year from the treatment, 10 (83.3%) had subsequent pregnancy. CONCLUSION: A combination of uterine artery MTX infusion and embolization with systemic MTX seems to be an effective and safe treatment for non-tubal ectopic pregnancies in women who try to conceive.

Tramadol-metoclopramide or remifentanil for patient-controlled analgesia during second trimester abortion: a double-blinded, randomized controlled trial.

STUDY OBJECTIVE: To compare patient-controlled analgesia (PCA) with tramadol with PCA with remifentanil in second trimester abortion. DESIGN: Prospective, randomized double-blinded study SETTING: University-affiliated medical center. PATIENTS: 30 ASA physical status 1 and 2 patients undergoing a second trimester abortion. INTERVENTIONS: Patients received PCA with either tramadol or remifentanil. Analgesia was initiated in the tramadol group by an initial loading dose of tramadol 1.0 mg/kg with 10 mg of metoclopramide followed by a PCA bolus of 0.3 mg/kg/mL of tramadol every 5 minutes. For remifentanil, which does not require a loading dose, a placebo of 100 mL of 0.9% normal saline was given followed by PCA of 0.4 µg/kg/mL every two minutes. MEASUREMENTS: Women were evaluated for pain via verbal analog score (VAS; 0-100), sedation, nausea, blood pressure, pulse, and respiratory rate. On the day of discharge, women were analyzed for overall satisfaction. Primary outcome was pain scores and general satisfaction. MAIN RESULTS: Analysis by time yielded no statistically significant difference in VAS scores between the groups at any point except 16-20 hours after induction of labor, when pain was lower in the tramadol group (11.3 ± 18.1 vs. 36.7 ± 27.4; P = 0.04). The average VAS score was low in both groups, with no significant differences noted between groups (P = 0.74). Satisfaction scores were high in both groups, with no significant differences noted between them (P = 0.89). CONCLUSION: Both drugs are acceptable choices for pain control in patients undergoing second trimester abortions.

Vascular endothelial growth factor A and its two receptors in human preantral follicles from fetuses, girls, and women.

OBJECTIVE: To investigate the expression of vascular endothelial growth factor A (VEGF-A) and that its two receptors (VEGFR1, VEGFR2) in human preantral follicles. DESIGN: Immunohistochemical, in situ hybridization, and reverse transcriptase polymerase chain reaction (RT-PCR) study of the expression of the VEGF-A system in human ovaries. SETTING: Major tertiary-care academic center. PATIENT(S): Twenty-two patients who underwent pregnancy terminations at 21-35 gestational weeks and 29 girls/women aged 5-39 years who underwent ovarian laparoscopies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Laboratory analysis of human ovarian specimens. RESULT(S): Immunhistochemistry and in situ hybridization revealed the expression of the proteins and mRNA transcripts for VEGFR1 and VEGFR2 in oocytes, granulosa cells, and stroma cells from fetuses and girls/women. The protein for VEGF-A was detected immunohistochemically in oocytes, granulosa cells, and stroma cells from fetuses and girls. VEGF-A and VEGFR1 proteins were expressed more strongly than VEGFR2. VEGF-A(121), VEGF-A(165), and VEGF-A(189) isoforms were identified by RT-PCR in the ovarian samples from fetuses and women. CONCLUSION(S): The presence of the VEGF-A receptors, particularly in the granulosa cells, suggests that VEGF-A might be involved in proliferation initiation of primordial follicles or play an as yet unknown role in human preantral follicles.

Bone morphogenetic protein 15 expression in human ovaries from fetuses, girls, and women.

OBJECTIVE: To investigate, for the first time, the protein expression of bone morphogenetic protein (BMP) 15 in human ovaries from fetuses, girls/women as well as its mRNA transcripts in ovaries from fetuses and girls. DESIGN: Controlled immunohistochemical and in situ hybridization study of expression of BMP-15 protein and mRNA transcripts in human ovaries. SETTING: Major tertiary care academic center. PATIENT(S): Nine patients that underwent pregnancy terminations at 21-33 gestational weeks and 18 girls and women aged 5-39 years that underwent ovarian laparoscopies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Immunohistochemistry (protein detection) in all specimens and in situ hybridization (mRNA detection) in specimens from fetuses and girls. Both procedures were conducted on paraffin sections. RESULT(S): The expression of the BMP-15 protein and its mRNA was identified already from primordial stages. Protein expression was detected in all oocytes and stroma cells from both ovarian sources, and in granulosa cells of specimens from girls and women. The mRNA transcripts were detected in the oocyte, granulosa, and stroma cells from fetuses and girls. CONCLUSION(S): The BMP-15 protein is expressed already at primordial stages in fetuses, girls, and women, and its mRNA transcripts in fetuses and girls. Further studies should be conducted to elucidate if indeed BMP-15 is involved in the activation of human primordial follicles.

Effects of basic fibroblast growth factor on in vitro development of human ovarian primordial follicles.

OBJECTIVE: To evaluate whether basic fibroblast growth factor (FGF) benefits the in vitro development of human primordial follicles. DESIGN: Human ovarian tissue was placed in organ culture for 4 weeks with basic FGF and either fetal calf serum or a serum-free combination. Control groups were cultured with a neutralizing antibody against basic FGF. SETTING: Major tertiary care and referral academic centers. PATIENT(S): Fourteen women/girls undergoing various gynecological operations and two fetuses from women undergoing pregnancy terminations. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Follicular counts, immunohistochemistry for proliferating cell nuclear antigen and bromodeoxyuridine incorporation and measurement of 17beta E(2) production. RESULT(S): Only in the serum-free culture system was the number of developing follicles in samples cultured with basic FGF significantly higher than in uncultured specimens. The E(2) production increased significantly in the second week, and there was a significant reduction in E(2) secretion with the addition of the neutralizing antibody against basic FGF. The percentage of granulosa cells (GCs) that stained for proliferating cell nuclear antigen or bromodeoxyuridine was significantly higher in developing follicles than in primordial follicles, regardless of treatment. CONCLUSION(S): Basic FGF apparently plays a role in the E(2) production of early follicles. High doses of basic FGF enhanced follicular development in serum-free media.

Growth hormone and its receptor in human ovaries from fetuses and adults.

OBJECTIVE: To investigate the presence of growth hormone (GH) and its receptor (GH-R) in early developing follicles. DESIGN: Immunocytochemical and in situ hybridization study. SETTING: Major tertiary care and referral academic centers. PATIENT(S): Ten ovarian samples from adults/girls aged 6-38 years and from 10 fetuses of women undergoing second and third trimester pregnancy terminations. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Immunocytochemistry and in situ hybridization on paraffin sections of human ovaries from fetuses and women/girls. RESULT(S): The proteins and the mRNA transcripts for GH and GH-R were detected in oocytes, granulosa (GC), and stroma cells from both sources (fetuses and women/girls), with low staining intensity only in a portion of the fetal GC. CONCLUSION(S): This is the first report of the expression of GH-R in human ovaries from fetuses as well as women/girls and of GH in human fetal ovaries. Be that as it may, further experiments should be conducted to elucidate if indeed GH is involved in the initiation of human primordial follicular growth.

Combined intrauterine and twin cervical pregnancy managed by a new conservative modality.

OBJECTIVE: To describe a rare case of a heterotopic pregnancy with two gestational sacs in the cervix and one in the uterine cavity. DESIGN: Case report. SETTING: Tertiary university hospital. PATIENT(S): A 45-year-old woman was diagnosed with a triplet gestation 7 weeks following IVF treatment for primary infertility of 5 years' duration. Transvaginal ultrasound scan revealed three gestational sacs: one sac inside the uterine cavity containing a live fetus, and two sacs in the uterine cervix, one containing a live fetus and a second empty sac. INTERVENTION(S): Pregnancy termination was performed by selective intraarterial catheterization of the uterine artery, intraarterial administration of methotrexate, and uterine artery embolization with Gelfoam. MAIN OUTCOME MEASURE(S): Intra- or postprocedural complications and fertility preservation. RESULT(S): The pregnancy termination was successfully performed without intra- or postprocedural complications, with preservation of the patient's fertility. CONCLUSION(S): Intraarterial methotrexate with uterine vessel embolization is an effective conservative approach to heterotopic cervical pregnancy.

Laparoscopic ovarian tissue preservation in young patients at risk for ovarian failure as a result of chemotherapy/irradiation for primary malignancy.

BACKGROUND: Aggressive chemotherapy/radiotherapy for cancer may cause gonadal failure in young female survivors. The putative aim of ovarian tissue cryopreservation is to restore fertility by transplantation of a patient's frozen-thawed ovarian tissue or, further into the future, by in vitro maturation of frozen-thawed oocytes followed by in vitro fertilization. This report presents our early experience with ovarian tissue preservation in young patients. METHODS: We conducted a database review of the techniques and outcomes of the ethics board-approved ovarian tissue cryopreservation procedures performed at our center since 1998 for young girls with malignancy. RESULTS: The study group included 23 patients (median age = 14 years) with various types of cancer (hematologic, bone, ovarian, or intracranial); 11 patients were scheduled for chemotherapy, 11 patients had already undergone some form of chemotherapy before the ovarian tissue harvesting, and 1 patient was not scheduled for chemotherapy. Ten underwent bone marrow transplantation after tissue retrieval. Twenty-one patients underwent laparoscopic harvesting of their ovarian tissue. In the other 2 patients, the ovary was preserved during inguinal hernia repair or tissue was obtained at laparotomy for a pelvic tumor. All patients had benign operative and postoperative courses. CONCLUSIONS: Laparoscopy for ovarian tissue retrieval for cryopreservation is safe in young cancer patients. Based on reports of successful cryopreservation of human ovarian tissue containing primordial follicles, we believe that this approach holds promise for female cancer survivors.

Possible direct cytoxicity effects of cyclophosphamide on cultured human follicles: an electron microscopy study.

PURPOSE: To evaluate the direct effect of cyclophosphamide on cultured human ovarian follicles. METHODS: Human ovarian cortical slices from premenopausal women were incubated with medium containing cyclophosphamide (0.0005-0.5 mg/mL) for 2-48 h and assessed by transmission electron microscopy. Noncultured specimens and samples cultured without cyclophosphamide were used as controls. RESULTS: There were significantly more damaged granulosa cell nuclei after incubation with 0.5 mg/mL cyclophosphamide for at least 4 h. There were also more changes in the basement membrane after incubation with cyclophosphamide at concentrations of 0.05 and 0.5 mg/mL. CONCLUSIONS: Although the cyclophosphamide dose that caused damage to the granulosa cell nuclei was above the pharmacological level, our results suggest that cyclophosphamide, and not only its active metabolite phospharamide mustard, might have a destructive effect on human follicles, as it remains in the circulation longer. This effect could be mediated by damage to the granulosa cells and perhaps the basement membrane.