Assisted conception following radical trachelectomy.

BACKGROUND: Radical trachelectomy (RT) has been established as a valuable fertility-preserving treatment in women with early stage cervical cancer. A number of these women will require assisted conception which may bring certain challenges to those managing treatment. An awareness of those challenges is essential to maximize outcome in terms of live birth rates. METHODS: All women who had undergone assisted conception following RT were assessed with respect to treatment management and pregnancy outcome. RESULTS: Pregnancy rates were good, with nine pregnancies in seven women treated. Difficulties in treatment were essentially related to isthmic stenosis. There was a clear need for trial embryo transfer (ET) prior to treatment and dilatation of the isthmus where necessary. The premature delivery rate was high (75% at <37 weeks), highlighting the importance of single ET to avoid multiple pregnancy. CONCLUSIONS: Assisted conception following RT is associated with a good pregnancy rate, although there is a high miscarriage and premature delivery rate. Treatment outcome should be maximized by careful patient preparation in terms of assessing the need for isthmic dilatation, and ET should be performed by an experienced operator.

Relevance of basal serum FSH to IVF outcome varies with patient age.

Live birth rate (LBR), age and basal serum FSH values were analysed in 1589 women undergoing their first cycle of IVF. Four age groups (<30, 30-34, 35-38, 39-45 years) and three FSH groups (<5, 5-9.9, > or =10 IU/l) were established. Logistic regression analysis was used to determine the effect of age and FSH on live birth. A model to predict the probability of a live birth suggests that an additional 10 years of age reduces the odds for live birth (OR = 0.66, 95% CI 0.48-0.91); an increase of FSH by 5 IU/l reduces the probability of live birth (OR = 0.75, 95% CI 0.61-0.92); women > or =39 years have an additional reduction in probability of live birth (OR = 0.58, 95% CI 0.61-0.92). Analysis by age and FSH categories showed that pregnancy rate (PR) did not change significantly with rising FSH for women <35 years old. In cycles started with serum FSH <5 IU/l, increasing age did not effect PR and LBR. Cycles started with serum FSH > or =10 IU/l had a PR and LBR of 23.6 and 16.9% respectively. The clinical relevance of elevated FSH varies according to age; younger women with elevated FSH and older women with low FSH still have an acceptable LBR.

The regulation of progesterone and hCG production from placental cells by interleukin-1beta.

We have investigated the roles of interleukin-1beta as a regulator of progesterone and chorionic gonadotrophin production from human placental cells. In primary placental cells IL-1beta increased hCG synthesis through a cyclic AMP-independent pathway, and was without effect on progesterone or cyclic AMP production. Since dibutyryl cyclic AMP increased progesterone production, this suggests that there is no coupling between the IL-1beta receptor and the adenylate cyclase enzyme in these cells. Immortalised trophoblast cells responded to IL-1beta by increasing progesterone production through a cyclic AMP-dependent mechanism, but hCG production by these cells was unaffected by IL-1beta or dibutyryl cyclic AMP. Further studies are needed to identify the role of IL-1beta as a possible regulator of progesterone production in primary placental cells. While hCG production in first-trimester trophoblast was increased by dibutyryl cyclic AMP and IL-1beta, both these effects may involve other factors such as IL-6, and their second messenger systems.

Formation and metabolism of 14,15-epoxyeicosatrienoic acid by human reproductive tissues.

Human granulosa-luteal cells cultured in the presence of arachidonic acid produced low levels of the epoxygenase metabolite 14,15-epoxy-5,8,11-(Z,Z,Z)-eicosatrienoic acid (14,15-EpETrE) as determined by HPLC analysis and gas chromatography mass spectrometry. When authentic 14,15-[3H]EpETrE was incubated with these cells in the absence of serum it was metabolised initially to the dihydroxy derivative (14,15-dihydroxy-5,8,11-eicosatrienoic acid, 14,15-DiHETrE) and subsequently to a number of more polar metabolites as determined by HPLC. Fetal calf serum protected 14,15-EpETrE from metabolism for at least 2 h. A similar pattern of metabolism was obtained when 14,15-[3H]EpETrE was incubated with a human choriocarcinoma cell line (BeWo). Microsomes from this cell line converted arachidonic acid to a large number of radioactive metabolites including 14,15-DiHETrE and 11,12-DiHETrE although there was no evidence for the parent epoxides. These results extend earlier findings that human reproductive tissues produce epoxygenase metabolites, and demonstrate the rapid metabolism of these compounds by intact cells in the absence of serum.

The regulation of platelet aggregation in vitro by interleukin-1beta and tumor necrosis factor-alpha: changes in pregnancy and in pre-eclampsia.

Platelet activation occurs in early pregnancy in women at risk of developing pre-eclampsia. Cytokines have been implicated in the pathogenesis of pre-eclampsia, so we determined the effects of interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha) on the in vitro aggregation of human platelets. IL-1beta increased aggregation of platelets from non-pregnant and pre-eclamptic women, and inhibited the aggregation of platelets from normal pregnant women. This latter effect was linked to a diminished P-selectin expression on ADP-stimulated whole blood platelets in normal pregnant women (p = 0.011). Platelet aggregation in response to ADP was found to be inhibited after preincubation with TNF-alpha in non-pregnant (38%, p = 0.01) and in normal pregnant women (54%, p = 0.001) and not affected in pre-eclamptic women. The inhibitory effects of TNF-alpha were mediated through the P75 receptor for TNF-alpha.

Second messengers and the control of progesterone production from first trimester trophoblast.

Basal progesterone production from first trimester placental cells in culture was high during the first 24 h of culture and fell to less than 30% of the initial level after 96 h in vitro. 22(R)-Hydroxycholesterol had a similar effect on progesterone production at all incubation times, indicating that the decline in basal steroidogenesis was not due to a loss of mitochondrial or post-mitochondrial enzymes. Continuous stimulation with dibutyryl (db) cyclic AMP maintained progesterone synthesis at a relatively constant high level despite the fall in basal progesterone production, and the optimum concentration of db cyclic AMP was 1.0 mM. The calcium ionophore A23187 had no effect on progesterone incubation during short-term cultures (<4 h), and inhibited steroidogenesis after 24 h. Repeated addition of A23187 during 96 h of culture also inhibited progesterone production. These findings indicate that progesterone production in human trophoblast is supported by a local factor which maintains a high level of steroid production through a cyclic AMP-dependent mechanism. The inhibitory effects of calcium ionophore in trophoblast differ from the stimulatory effects of this compound in other steroidogenic cells, but the reasons for the difference are not known at present.

The production of progesterone and 5,6-epoxyeicosatrienoic acid by human granulosa cells.

Previous investigations have implicated epoxygenase metabolites of arachidonic acid in the control of steroidogenesis in luteinised granulosa cells. The aim of this study was to assess this hypothesis further. We first determined the responsiveness of the cells in vitro to three different stimuli, namely luteinising hormone (LH), interleukin-1beta (IL-1beta), and dibutyryl cyclic AMP (db. cyclic AMP). Their effects were time-dependent, in that progesterone production from cells incubated for 3 days prior to stimulation responded strongly to db. cyclic AMP, to a lesser extent to LH and not to IL-1beta. After 6 days of preincubation, all three stimuli increased progesterone production, and this preincubation period was used in the remainder of the study.LH and IL-1beta increased the intracellular levels of 5,6-epoxyeicosatrienoic acid (5,6-EpETrE) maximally after 10 min, whereas db. cyclic AMP had a more rapid effect within 2-5 min. There were no changes in levels of 14,15-epoxyeicosatrienoic acid (14,15-EpETrE), indicating that the effect was specific. Levels of dihydroxy derivatives of arachidonic acid were also increased, suggesting rapid metabolism of 5,6-EpETrE to inactive 5,6-DiHETrE. The effects of 5,6-EpETrE on progesterone production were transient, which may be due to the lability of this compound in solution, and limited passage into the granulosa-luteal cell cytoplasm. These results support a role for 5,6-EpETrE in the production of progesterone by human granulosa-luteal cells.

Production of intracellular arachidonic acid metabolites by human granulosa cells.

The major intracellular metabolites of arachidonic acid within human granulosa cells are an epoxy-eicosatrienoic acid (EET), and a dihydroxy-metabolite. The former which was present at higher levels, co-migrated with 5,6-EET on HPLC. Incubation of the cells with LH for 5 min stimulated the production of both 5,6-EET and the dihydroxy compound 2-4 fold. The production of other intracellular arachidonic acid metabolites was unaffected by stimulation with LH. These results suggest that one or both of these metabolites may have a role in steroidogenesis in human granulosa cells.

Equivalent inhibition of in vivo platelet function by low dose and high dose aspirin treatment.

In vitro platelet function was inhibited in healthy volunteers by two different doses of aspirin, as confirmed by measurement of maximum serum production of thromboxane B2 (TXB2) by platelets. 75 mg aspirin did not fully inhibit serum TXB2 production after 24 hours, whereas 300 mg aspirin did. Inhibition of platelet function in vitro was maintained by both 75 mg/day aspirin or 300 mg/alternate day aspirin. In contrast, in vivo production of TXB2, measured as urinary levels of the 11-keto-TXB2 metabolite, was inhibited similarly by both doses of aspirin throughout the study. These findings suggest that 75 mg/day aspirin may be sufficient adequately to inhibit platelet aggregation in vivo.

Early miscarriage and fetal malformations after induction of ovulation (by clomiphene citrate and/or human menotropins), in vitro fertilization, and gamete intrafallopian transfer.

From the reviewed data, it appears that CC, hMG-hCG, or the association of these drugs with IVF-ET and GIFT programs do not carry an increased risk for congenital malformations as a whole, nor is there any specific malformation that has an increased incidence or is related in any way with the use of these drugs. Table 7 represents the specific malformation rate per 1,000 births in the general population and in newborns delivered after treatment with CC, hMG-hCG, or IVF-ET and GIFT. The malformation rate in the treated groups does not differ from that of the general population. However, as shown by McIntosh et al., the incidence of congenital malformations often rises with a longer follow-up. Most of the reports about babies born after ovulation induction are based on the initial examination done shortly after birth. Thus, studies including examination of these infants up to at least 12 months of age will be undoubtedly of value. Also, data concerning the reproductive capability of women born after ovulation induction is lacking. With regard to the abortion rate in pregnancies achieved after such treatments and procedures, it can be concluded that it does not appear to be higher than that of the general population, particularly when early pregnancy loss, advanced maternal age, the infertility status, and the increased incidence of multiple pregnancies occurring in these patients are taken into consideration.

Adult respiratory distress syndrome complicating ovarian hyperstimulation syndrome.

A rare case of OHSS complicated by an ARDS from which the patient recovered after appropriate treatment is presented. Pulmonary capillary leakage induced by prostaglandin release, hypoalbuminemia, and shift of dextran 40 macromolecules to the intraalveolar space is considered the most probable reason for this complication.

Comparison of intravenous albumin and transfer of fresh embryos with cryopreservation of all embryos for subsequent transfer in prevention of ovarian hyperstimulation syndrome.

OBJECTIVE: To compare the efficacy of administration i.v. albumin to prevent severe ovarian hyperstimulation syndrome (OHSS) in patients undergoing ovarian stimulation for IVF with a standard policy of cryopreserving all embryos and to assess the impact of the two methods of treatment on pregnancy rates (PRs). DESIGN: Prospective randomized study. SETTING: A tertiary referral center for assisted conception. PATIENTS: Twenty-six patients undergoing IVF treatment cycles who were considered to be at high risk of developing severe OHSS on the basis of their serum E2 concentrations on the day of hCG administration and the number of oocytes collected. INTERVENTION: In group 1 (n = 13) all the generated embryos were cryopreserved to be transferred subsequently in hormonally manipulated cycles. In group 2 (n = 13) patients received IV infusions of albumin on the day of oocyte retrieval and 5 days later. Patients in group 2 had transfers of fresh embryos. MAIN OUTCOME MEASURES: The total dosage of hMG used, total number of follicles developed, number of follicles > 14 mm in diameter, serum E2 concentrations and endometrial thickness on day of hCG administration, number of oocytes retrieved, number and quality of embryos generated, PRs per cycle commenced, and onset and degree of any OHSS developed. RESULTS: There were no significant differences in the above parameters between the two groups, except for PRs that were significantly higher in patients who had all embryos cryopreserved (38.6% versus 0%). CONCLUSION: The policy of cryopreserving all generated embryos appears as effective as the administration of i.v. albumin in preventing OHSS in high-risk patients and produces significantly higher PRs.

The regulation of arachidonic acid metabolism in human first trimester trophoblast by cyclic AMP.

Human trophoblast cells are known to release a range of arachidonic acid metabolites into culture medium, including cyclo-oxygenase, lipoxygenase and epoxygenase products. In this study we investigated the effects of dibutyryl cyclic AMP (db cAMP) on arachidonic acid metabolism in human first trimester trophoblast cells, and also determined the distribution of metabolites between intracellular and extracellular compartments. db cAMP increased intracellular levels of radioactivity within 2 min, and extracellular levels of radioactivity were increased after 30 min. These changes were reflected in increased levels of arachidonic acid metabolites in both compartments, indicating that arachidonic acid was metabolised. db cAMP increased intracellular levels of 5,6-epoxyeicosatrienoic acid (5,6-EpETrE) within 2 min of addition to cultured cells. No changes were detected after 5-10 min, but substantial changes were found 30 min after the addition of db cAMP. The dihydroxyeicosatrienoic acid (DiHETrE) breakdown products also increased with similar kinetics. In contrast, levels of 14,15-EpETrE increased after 5-10 min.

Transverse uterine incision for cesarean delivery of the transverse-lying fetus.

Low-isthmic transverse uterine incision was performed in 66 patients during Cesarean section indicated for transverse fetal lie. No significant differences were noted in the 1 and 5 min Apgar scores among fetuses delivered before or after rupture of the membranes. In only 5 (7.6%) of these cases was the incision converted into an inverted-T. The 1 min Apgar score was significantly lower in this group (6.0 +/- 1.3) compared to the rest of the group (7.5 +/- 1.7, P less than 0.01), however, the 5 min score showed no significant difference. No significant complications were noted in the post-operative course of mother and fetuses. We concluded that the transverse uterine incision is safe for the Cesarean delivery of the transverse-lying fetus.

Unsuspected involvement of the female genitalia in pemphigus vulgaris.

A 56-year-old woman had erosions due to pemphigus vulgaris in the inner thighs and perineum. The cutaneous lesions cleared following intramuscular gold therapy. However, because of complaints of dyspareunia, a colposcopic examination was performed and involvement of the cervix was demonstrated. The need for a vaginal examination in the monitoring of pemphigus vulgaris is emphasized.

Solitary thick intra-uterine membranes not associated with the amniotic band syndrome; three case reports.

Three cases in which a single intra-uterine membrane with a free and thickened edge was identified by ultrasound antenatally are presented. The bands turned out to be thickenings of the fetal membranes. In one case intra-uterine adhesions were documented by hysterosalpingography (HSG) and hysteroscopy before conception. One infant suffered from hypospadias. The diagnosis of intra-uterine bands or membranes should turn our attention to a possible intra-uterine pathology.

Reproductive ageing in women.

The traditional view in respect to female reproduction is that the number of oocytes at birth is fixed and continuously declines towards the point when no more oocytes are available after menopause. In this review we briefly discuss the embryonic development of female germ cells and ovarian follicles. The ontogeny of the hypothalamic-pituitary-gonadal axis is then discussed, with a focus on pubertal transition and normal ovulatory menstrual cycles during female adult life. Biochemical markers of menopausal transition are briefly examined. We also examine the effects of age on female fertility, the contribution of chromosomal abnormalities of the oocyte to the observed decline in female fertility with age and the possible biological basis for the occurrence of such abnormalities. Finally, we consider the effects of maternal age on obstetric complications and perinatal outcome. New data that have the potential to revolutionize our understanding of mammalian oogenesis and follicular formation, and of the female reproductive ageing process, are also briefly considered.

New immunochemical method for rapid detection of human choriogonadotropin in urine.

We describe a visual assay for rapid detection of choriogonadotropin (hGC) in human urine, and evaluate a pregnancy test kit that is based on this assay and designed for use by the general public. The assay involves the formation of an antibody-antigen complex between the anti-hGC antibodies coated on the membrane protein of Staphylococcus aureus bacteria, prestained with hematoxylin, and the hGC concentrated on a column of Sepharose-concanavalin A. The test was calibrated to detect as little hGC as 0.9 (SD 0.15) int. unit/mL. The kit, clinically tested with 448 urine samples, was 99.6% accurate. Simple to perform, the test gives highly reliable results as early as five days after the missed menstrual period.

Polyhydramnios caused by giant alveolar granular cell myoblastoma.

Congenital granular cell myoblastoma of the newborn is a rare tumor. The combination of polyhydramnios caused by obstruction of the infant's mouth by this tumor is extremely rare, and this is the first published report of such a condition.

Malignant fibrous histiocytoma of the vagina and vulva successfully treated by combined chemotherapy and radiotherapy.

Combined vaginal and vulvar malignant fibrous histiocytoma has not been reported previously. Radical vulvectomy with node dissection is the currently recommended therapy for a vulvar lesion of this type. We present a case with complete tumor regression after combined chemotherapy and radiotherapy. The surgical approach in our patient was inappropriate due to advanced disease. Follow-up examinations for 6 years after initiation of therapy showed no evidence of local recurrence or distant metastasis. Chemotherapy followed by radiotherapy should be considered as an alternative to surgery in patients with advanced vaginal and vulvar involvement and in patients in whom complex medical problems preclude extensive surgical procedures.