Tubal superfetation following frozen-thawed single-embryo transfers in two separate cycles: Case report and literature review.

Superfetation is a very rare occurrence. In the context of assisted reproduction, it has been reported only as an intrauterine pregnancy after ovarian stimulation and/or embryo transfer in the presence of an undiagnosed ectopic pregnancy. Here we report a case of a 27-year-old anovulatory patient, gravida 1 para 1, who underwent two frozen-thawed single-blastocyst transfers in separate cycles. The patient reported that 12 days after the first transfer, she had menstrual bleeding and stopped her estradiol and progesterone supplementation without undergoing a blood human chorionic gonadotropin (ßhCG) test. At her request, a second cycle was immediately initiated, with endometrial thickness measuring 4 mm. Eleven days after the second transfer, the ßhCG value was inappropriately high. A right tubal pregnancy corresponding to 8 gestational weeks was diagnosed. Laparoscopy revealed a prominent right tubal pregnancy in addition to a significantly smaller left tubal pregnancy. The discordant tubal pregnancies were confirmed histologically. To our knowledge, superfetation involving a second ectopic pregnancy coexistent with a first, contralateral ectopic pregnancy consequent to consecutive in vitro fertilization procedures has not previously been described in the medical literature. This case emphasizes the importance of routine ßhCG testing after every IVF cycle, even if apparently unsuccessful.

Escalating placenta invasiveness: repeated placenta accreta at the limit of viability.

Placenta percreta is an obstetric condition in which the placenta invades through the myometrium. This is the most severe form of placenta accreta and may result in spontaneous uterine rupture, a rare complication that threatens the life of both mother and fetus. In this case report, we describe a 32-year-old woman in her fourth pregnancy, diagnosed with repeated placenta accreta, which was eventually complicated by spontaneous uterine rupture at 24 weeks' gestation. This patient had a history of abnormal placentation in prior pregnancies and previous uterine injuries. This case demonstrates a pattern of escalating placental invasiveness, and raises questions regarding the process of abnormal placentation and the manifestation of uterine rupture in scarred uteri.

Reproductive outcomes following uterine septum resection.

OBJECTIVE: To determine the reproductive outcome following hysteroscopic septum resection in women with a septated uterus and a history of spontaneous miscarriages or premature deliveries. STUDY DESIGN: A retrospective, cohort study investigating reproductive outcomes following septum resection was conducted. Patients who had no other apparent cause for spontaneous miscarriage or preterm delivery were included in the study. Reproductive outcomes were compared between pregnancies prior to and after the septum resection. Multiple pregnancies were excluded. RESULTS: Twenty-eight patients met the inclusion criteria with a total of 85 pregnancies, 45 prior and 40 after septectomy. The mean gestational age increased from 33.73 ± 6.27 (weeks) prior to the resection to 38.47 ± 1.71 (weeks) after it (p < 0.05). The mean birth weight increased from 2520 ± 764.4 (g) to 3202.6 ± 630.2 (g) after the resection. Spontaneous miscarriage rate dropped from 63.6% to 12.5%. Multivariate analysis models showed uterine septectomy to be independently associated with increased gestational age at delivery (ß = 0.606, Adjusted R(2 )= 0.328, CI 10.647-20.612, p < 0.01), increased birth weight (ß = 0.424, Adjusted R(2 )= 0.129, CI 202.097-1210.287, p < 0.01) and with lower risk for preterm delivery (OR = 0.073, CI 0.16-0.327, p < 0.01). CONCLUSION: Hysetroscopic resection of a uterine septum improves reproductive outcomes in women with a septated uterus and a history of spontaneous miscarriages or premature deliveries.

Inguinal hernia as a presentation of testicular feminization.

We present a case of a 20-year-old female who was admitted to our department for an elective inguinal hernia repair. An oval-shaped mass was found in the hernia sac during the surgery that was suspected to be an ovary. Histological examination revealed testicular tissue. Further evaluation confirmed testicular feminization. She underwent laparoscopic orchiectomy and hernia repair from the contralateral side 3 months later.

"Habitual adnexal torsions"--recurrence after two oophoropexies in a prepubertal girl: a case report and review of the literature.

BACKGROUND: Recurrent adnexal torsion rarely affects girls. Various surgical techniques for its prevention are available. We describe a case of recurrent asynchronous bilateral torsions in a prepubertal patient. CASE: An 8-year-old girl first presented with a right adnexal torsion and underwent a laparoscopic untwisting. During the following 3 years, 4 additional laparoscopies were required for treatment of left adnexal torsions. Although undergoing bilateral utero-ovarian ligament plication twice, torsion recurred. After examining the various options, we fixated the left ovary to the sidewall just below the pelvic brim. SUMMARY AND CONCLUSION: In the absence of clear evidence, treatment should be flexible and dependent on the individual case. Thorough patient education is imperative in order to prevent a delay in diagnosis and treatment of recurrent adnexal torsion.

Laparoscopic management of ureteral endometriosis: our experience.

STUDY OBJECTIVE: Ureteral endometriosis is rare, accounting for less than 0.3% of all endometriotic lesions. The aim of our study is to evaluate the prevalence of extrinsic ureteral endometriosis in women undergoing laparoscopic surgery for severe endometriosis and to suggest that laparoscopic ureterolysis represents a mandatory measure in all cases to avoid ureteral injury. METHODS: A retrospective analysis was performed of all cases of patients who underwent laparoscopic surgery for severe endometriosis at the departments of obstetrics and gynecology at CMCO-SIHCUS and Hautepierre Hospital, Strasbourg, from November 2004 through January 2006. MEASUREMENTS AND MAIN RESULTS: We recorded 54 patients with a mean age of 31 years and a mean body mass index of 21.9. Reported symptoms were dysmenorrhea (88%), severe dyspareunia (88%), severe pelvic pain (38.8%), and infertility (74%). Five women presented with dysuria, frequency, recurrent urinary tract infections, and pain in the renal angle, and 2 patients had hydronephrosis. We observed 3 patients (5.6%) with ureteral stenosis, 35 (64.8%) with adenomyotic tissue surrounding the ureter without stenosis, and 16 (29.6%) with adenomyotic tissue adjacent to the ureter. It was on the left side in 47.4% of cases, on the right side in 31.6% cases, and bilaterally in 21% of cases. In 9 patients, ureteral involvement was associated with bladder endometriosis (16.7%). In all patients, ureterolysis was performed. There was 1 case of ureteral injury during the procedure, 2 of transitory urinary retention, and 1 of uretero-vaginal fistula after surgery. During the first year of follow-up, the disease recurred in 4 patients, with no evidence of the disease in the urinary tract. CONCLUSION: Conservative laparoscopic surgery to relieve ureteral obstruction and remove pathologic tissue is the management of choice. Resection of part of the ureter should be performed only in exceptional cases. Ureterolysis should be performed in all patients before endometriotic nodule resection to recognize and prevent any ureteral damage.

Intrinsic fluorescence polarization of amniotic fluid: II. Toward a noninvasive method for the determination of fetal lung maturity.

The present study compares two methods for the determination of fetal lung maturity: the novel intrinsic fluorescence polarization ratio (IFPR) and the commercial TDx-FLMII. Amniotic fluid (AF) samples were collected from 69 women during the second and third trimesters of singleton pregnancies. Thirty-three samples were tested for IFPR only after centrifugation, and the rest were examined both before and after centrifugation. Of the latter 33 samples, 29 were assessed for lung maturity with the TDx-FLMII method as well. The results showed that IFPR values decreased with the advance in gestational age (r = 0.77, p < 0.05, n = 69). A significant correlation was found between IFPR of centrifuged and noncentrifuged samples (r = 0.94, p < 0.05, n = 36). A significant correlation was demonstrated between IFPR and TDx-FLMII values of centrifuged (r = 0.75, p < 0.05, n = 29) and noncentrifuged (r = 0.63, p < 0.05, n = 29) samples and moreover, samples considered mature by TDx-FLMII had low values of IFPR (n = 10). It can be concluded that the IFPR method can utilize noncentrifuged AF, thus suggested as a potential noninvasive method.

X-linked spondyloepiphyseal dysplasia tarda: a novel SEDL mutation in a Jewish Ashkenazi family and clinical intervention considerations.

X-linked spondyloepiphyseal dysplasia tarda (SEDT; MIM 313400) is a late onset progressive skeletal disorder, which manifests in childhood and is characterized by disproportionate short stature with a short trunk, barrel chest and absence of systemic complications. We found a single-nucleotide deletion in position 613 of the SEDL gene in two brothers of Jewish-Ashkenazi ancestry afflicted with the disease. This is the first description of SEDL mutations in a Jewish family. Following this finding, an eight-month old second cousin of the brothers, who had yet no clinical or radiological signs of the disease, was found to carry the deletion. Another relative, 24-years old, carrying the same mutation was 1.61 m tall and had only minimal signs of the disease. These findings raise the dilemma of pre-natal counseling in SEDL and the need for exploring means of early intervention in pre-symptomatic cases.