Comparison of clinical outcomes and spectral Doppler indices of uterine and ovarian stromal arteries in women undergoing myomectomy with or without hypogastric arterial ligation.

OBJECTIVE: To compare clinical outcomes and hemodynamic alterations of uterine and ovarian stromal arteries between patients with symptomatic myomas undergoing myomectomy preceded by arterial ligation and those undergoing myomectomy alone. METHODS: In this prospective, non-randomized comparative study, myomectomy was performed on 69 women with symptomatic myomas. Myomectomy alone was performed in 31 patients (Group I) and myomectomy with concomitant bilateral hypogastric arterial ligation was performed in 38 patients (Group II). In both groups, surgical results and clinical outcomes were evaluated by peripheral hemoglobin levels, a pictorial blood-loss assessment chart, and visual analog scales. Spectral Doppler indices of uterine and ovarian stromal arteries, including peak systolic velocity, end-diastolic velocity, pulsatility index and resistance index were performed preoperatively, and 1 day and 1 or more months postoperatively. RESULTS: Twenty-two patients in Group I and 31 patients in Group II received regular follow-up examinations for a mean follow-up period of 10.1 months. Menstrual flow, dysmenorrhea and hemoglobin levels improved significantly after surgery in both groups. Blood loss during surgery was less in Group II than it was in Group I (P=0.02). Doppler indices of uterine and ovarian stromal arteries from preoperation to mean follow-up point were not significantly different between the groups, except for a significantly lower uterine artery pulsatility index in Group II (P=0.01). CONCLUSIONS: Myomectomy with hypogastric arterial ligation for symptomatic myomas is as efficient as is myomectomy alone and reduces blood loss during surgery. Serial Doppler studies showed that hypogastric ligation does not block uterine and ovarian perfusion, and even reduces the impedance of the uterine arteries. The long-term recurrence rate after myomectomy with hypogastric arterial ligation remains to be determined.

Determination of the efficiency of controlled ovarian hyperstimulation in the gonadotropin-releasing hormone agonist-suppression cycle using the initial follicle count during gonadotropin stimulation.

PURPOSE: Our purpose was to evaluate the relationship between the initial follicle count during gonadotropin stimulation after gonadotropin-releasing hormone (GnRH) agonist suppression and the efficiency of controlled ovarian hyperstimulation (COH) in patients receiving treatment with assisted reproductive technologies (ARTs). METHODS: A total of 338 COH procedures in 291 couples was performed with cycles that reached the stage of oocyte retrieval. The ovarian antral follicle number was measured using transvaginal ultrasonography at the folliculometry during gonadotropin stimulation by GnRH agonist suppression in patients undergoing ARTs. Controlled ovarian hyperstimulation was accomplished using GnRH agonist down-regulation combined with FSH and menotropin stimulation. The characteristics of oocytes after retrieval and embryos after in vitro culture and the pregnancy rates were assessed. RESULTS: The procedures performed included 195 ET cycles, 129 TET cycles, and 14 incomplete cycles. The treatment cycles were divided into four categories according to the antral follicle number (i.e., < or = 5, 6-10, 11-15, and > or = 16) at the first folliculometry to evaluate the influence of various factors. The antral follicle count correlated significantly with the patient age, dosage of gonadotropins, serum estradiol concentration, number of antral follicles (> or = 13 mm) while receiving hCG injections, number of oocytes retrieved, and, later, number of embryos transferred. There was a trend toward an increasing number of pregnancies per cycle as the number of antral follicles increased (14.7, 26.5, 44, and 45%, respectively). CONCLUSIONS: We were able to predict the efficiency of COH and outcome of ARTs based on the follicle count during the first folliculometry during gonadotropin stimulation after GnRH agonist suppression. The results of the folliculometry significantly predicted the ovarian response to COH and the outcome of ARTs in the current treatment cycle.

Clinical implications of intracytoplasmic sperm injection using cryopreserved testicular spermatozoa from men with azoospermia.

OBJECTIVE: To investigate whether sperm obtained by testicular sperm extraction (TESE) and cryopreserved well before intracytoplasmic sperm injection (ICSI) can serve as an effective sperm source. STUDY DESIGN: The role of cryopreserved testicular spermatozoa was evaluated in a retrospective analysis of consecutive ICSI cycles using fresh or cryopreserved sperm; they were followed by prospective, planned treatment using cryopreserved sperm with a modified ICSI procedure. Sixteen men (22 cycles) with obstructive or nonobstructive azoospermia were included in the retrospective analysis. Another 25 men (29 cycles) were in the planned treatment group. Following these series, the pregnancy outcomes were compared between ICSI cycles with fresh or cryopreserved testicular sperm. RESULTS: In the retrospective phase, 14 ICSI cycles were performed using fresh sperm, with 8 using cryopreserved sperm. There were no statistically significant differences between the two groups in any outcome measure. Planned treatment with cryopreserved sperm resulted in a fertilization rate of 84% and an embryo transfer rate of 89%. Thirteen couples (44%) achieved pregnancy (five ongoing, six delivered). These rates were similar to those in the retrospective phase of the study. All couples in the planned cryopreservation group had multiple aliquots (6.5 +/- 2.1) of sperm remaining after the first cycle. CONCLUSION: Cryopreserved sperm obtained by TESE can be used as an effective sperm source in ICSI cycles. Planned cryopreservation allows multiple aliquots to be stored for use in subsequent cycles and thus avoids the need for repeat biopsies.

Influence of polyvinylpyrrolidone on the outcome of intracytoplasmic sperm injection.

OBJECTIVE: To assess the effectiveness of a procedure for intracytoplasmic sperm injection (ICSI) modified so as not to use polyvinylpyrrolidone (PVP) and to examine clinical outcome. STUDY DESIGN: Seventy-seven cycles of ICSI were performed over a one-year period. PVP was used for sperm immobilization in 39 of these cycles and was eliminated from the other 38 cycles. Difference in fertilization rate, cleavage rate, parthenogenetic activity, clinical pregnancy rate, ongoing pregnancy rate and grading of preembryos between the two groups was compared. RESULTS: The non-PVP group had a higher fertilization rate (57.63% vs. 84.43%, P < .001) and better preembryo quality (chi 2 = 6.80, P = .009) than the PVP group. There was no significant difference in cleavage rate, parthenogenetic activity, clinical pregnancy rate and ongoing pregnancy rate between the two groups. CONCLUSION: Performing ICSI without PVP may improve the fertilization rate and preembryo grading. However, further study with a larger cohort is necessary to determine whether the modified procedure can increase the pregnancy rate.

The expression of DAZL1 in the ovary of the human female fetus.

OBJECTIVE: To determine whether DAZL1 is expressed in human fetal ovarian tissue. DESIGN: The presence of DAZL1 expression was determined by reverse transcriptase polymerase chain reaction (RT-PCR). SETTING: Academic tertiary care medical center and research unit of university. PATIENT(S): Five female abortuses between the 19th and 22nd week of gestational age. INTERVENTION(S): Fetal ovarian tissues were collected immediately after the cessation of the heart beat. MAIN OUTCOME MEASURE(S): The product of RT-PCR. RESULT(S): DAZL1 expression was detected in all five samples. CONCLUSION(S): DAZL1 is not only expressed in human testes but also in ovaries. It may play a role in germ cell survival and gonad development in both sexes.

Maternal serum screening for down syndrome in pregnancies conceived by intra-uterine insemination.

The purpose of our study was to assess the influence of intra-uterine insemination (IUI) on the results of maternal serum Down syndrome screening. 43 women with IUI pregnancies and 4507 healthy women who conceived were studied. Ovulation in IUI pregnancies was induced by clomiphene and/or human menopausal gonadotrophin (hMG). Maternal serum levels of free beta-human chorionic gonadotrophin (hCG) and alpha-fetoprotein (AFP) were measured for Down syndrome screening. It was considered screen-positive when the risk of Down syndrome was 1 in 270 or greater in the second trimester. The value of maternal serum AFP was significantly lower in the IUI group (median=0.760 MoM) than in the control group (median=1.050 MoM). However, the value of free beta-hCG was not significantly different between the two groups. The positive rate of maternal serum Down syndrome in IUI pregnancies was similar to that of the control group. Our results indicate that IUI pregnancy may be associated with a lower level of AFP, although the mechanism for this difference remains unknown.

Effects of short-course buserelin therapy on adenomyosis. A report of two cases.

BACKGROUND: Hysterectomy and hysteroscopic endometrial ablation remain common treatment of symptomatic adenomyosis for women who have completed childbearing. However, for patients who wish to avoid surgery and in whom adenomyosis is suspected of causing infertility, repeated abortion or physical symptoms, medical treatment with gonadotropin-releasing hormone analogue (GnRH-a) should be considered. CASES: Two cases of documented adenomyosis were suspected of causing infertility; both were treated with a three-month course of GnRH-a via a nasal spray. Both patients experienced relief of symptoms and conceived within six months of the cessation of treatment. CONCLUSION: The efficacy and safety of a short course of GnRH-a treatment of adenomyosis may be considered in patients who take less time than others to achieve a significant reduction of uterine size and relief of symptoms and in those who develop side effects.

Adult ovarian granulosa cell tumors: spectrum of sonographic and CT findings with pathologic correlation.

OBJECTIVE: The objective of this study was to evaluate the spectrum of sonographic and CT findings in adult ovarian granulosa cell tumors with pathologic correlation. MATERIALS AND METHODS: Transabdominal sonograms and CT scans in 13 patients with pathologically proven adult ovarian granulosa cell tumors were retrospectively reviewed. Morphologic characteristics of the lesions shown on sonography and CT were correlated with the histopathologic findings. RESULTS: On the basis of sonographic and CT findings, 13 cases of adult ovarian granulosa cell tumor were categorized into five morphologic patterns: multilocular cystic (n = 6), thick-walled unilocular cystic (n = 2), thin-walled unilocular cystic (n = 1), homogeneously solid (n = 2), and heterogeneously solid (n = 2) masses. Histopathologically, the multilocular cystic masses were characterized by a predominately macrofollicular pattern of granulosa cells and multiple cystic spaces with watery fluid or hemorrhage. Unilocular central cystic masses seen on CT correlated pathologically with confluence and expansion of the cystic spaces. Homogeneously solid masses seen on sonography and CT were correlated with evenly distributed trabecular or diffuse patterns in the tumor cells. Intratumoral bleeding, infarcts, fibrous degeneration, and irregularly arranged tumor cells yielded heterogeneously solid tumors. CONCLUSION: Adult ovarian granulosa cell tumors have a varied histologic appearance and a varied arrangement of tumor cells, both of which can create a spectrum of imaging manifestations. Appreciation of these manifestations is helpful in the diagnosis of this tumor.

Prenatal diagnosis of de novo interstitial deletion of proximal 4q by maternal serum screening for Down syndrome.

Deletion of the proximal portion of chromosome 4q is apparently rare. To our knowledge, prenatal diagnosis of the interstitial deletion of 4q12-21.1 has never been reported. We present a prenatal case of 4q deletion in association with a positive Down syndrome screening test of an elevated maternal serum free beta human chorionic gonadotrophin (beta-hCG) level. The prenatal sonogram revealed intra-uterine growth retardation (IUGR) and shortening of the femur. Facial dysmorphism included micrognathia, depressed nasal bridge and low-set ears, these anomalies were evident at the postnatal examination. All of the anomalies were consistent with those described in proximal 4q deletion syndrome. Our case suggests that chromosome studies may be indicated for patients with high maternal serum free beta-hCG and IUGR in the early second trimester.

Conservative management of early endometrial adenocarcinoma with repeat curettage and hormone therapy under assistance of hysteroscopy and laparoscopy.

We report a rare case of early-stage endometrial adenocarcinoma in a 22 year old nullipara with polycystic ovaries undergoing conservative treatment. Pretreatment evaluation including tumour grade, depth of myometrial invasion, tumour size, hormone receptor status and flow cytometric analysis indicated a favourable prognosis. The patient underwent repeat endometrial curettage and a 6 month period of therapy with megestrol acetate and tamoxifen. A combination contraceptive pill was then prescribed to ensure withdrawal of the menstrual cycle thereafter. Now, 1 year after the last curettage, there is no evidence of disease. During the treatment period, hysteroscopy allowed for a more precise approach in panoramically examining the tumour nest in the endometrial cavity, and the subsequent endometrial response to hormone therapy. Laparoscopy using bulldog clamps applied to the isthmic portion of the Fallopian tubes prevented i.p. spread of endometrial tissue from retrograde regurgitation during hysteroscopy. Laparoscopic ovarian electrocautery resulted in the reduction of abnormal hypervascularization on the surface of polycystic ovaries postoperatively but caused a peri-ovarian adhesion complication. It is interesting that this case posed a unique opportunity to demonstrate the tumour regression under the assistance of laparoscopy and hysteroscopy.

Comparison of laparoscopically assisted vaginal hysterectomy and abdominal hysterectomy in taiwan.

In order to clarify the feasibility of laparoscopically assisted vaginal hysterectomy (LAVH) using a not-for-extra charge instrument and to determine its cost-effectiveness in the Taiwan national health care system, we designed a prospective comparison which recruited candidates with nonmalignant uterine tumors prepared for hysterectomy to assess treatment by the laparoscopic versus the laparotomic approach. There were 144 patients in the laparoscopic group and 157 patients in the laparotomic group. The two groups were similar in characteristics. A total of 138 LAVHs were completed with six conversions (4.2%) to abdominal hysterectomy. Intraoperatively, the mean operating time in the LAVH group was longer than in the laparotomic group (134 vs 112 minutes, p < 0.001). No statistically significant differences were found between the two groups in mean estimated blood loss (260 vs 259 mL) and complications (5.8 vs 4.5%). Postoperatively, mean flatulence-relief time (27.4 vs 31.3 hours) and intramuscular meperidine requirements (1.6 vs 2.5 ampoules, 1 ampoule = 50 mg) were significantly less with LAVH. There were no differences in mean hemoglobin levels (10.7 vs 10.9 g/dL), complications (9.4 vs 13.4%, p = 0.288), or hospital stay (4.9 vs 5.2 days, p = 0.058). The mean total hospital charges (NT$48,390 vs 41,649) and insurance-paid costs (NT$43,992 vs 38,389) were significantly greater in the LAVH group. In conclusion, LAVH when performed by an experienced laparoscopist and for adequately selected patients, permits a better short-term convalescence, but is more expensive compared with conventional abdominal hysterectomy.

Use of laparoscopy in intersex patients.

PURPOSE: Management of impalpable gonads in intersex patients remains a challenging problem. Since laparoscopic gonadectomy or gonadal preservation has been used in the management of impalpable gonads in the normal male population, laparoscopy can be an alternative method in the treatment of intersex patients. MATERIALS AND METHODS: Laparoscopic operations were performed on 6 patients with intersex conditions, including the testicular feminization syndrome in 2, 17 beta-hydroxysteroid dehydrogenase deficiency in 1, 5 alpha-reductase deficiency in 1 and mixed gonadal dysgenesis in 2. RESULTS: Laparoscopic gonadal biopsy, gonadectomy and hysterosalpingectomy were done in select patients. CONCLUSIONS: Although the initial diagnoses were made by phenotypic presentation, and biochemical and cytogenetic studies, laparoscopy had an important role in defining the internal ductal and gonadal structures to confirm the diagnosis, and served as an efficient method for gonadectomy and removing structures contrary to the assigned gender.