Induction of final follicle maturation with a gonadotropin-releasing hormone agonist in women at risk of ovarian hyperstimulation syndrome undergoing gonadotropin stimulation and intrauterine insemination: proof-of-concept study.

OBJECTIVE: To evaluate the reproductive performance and safety of gonadotropin-stimulated intrauterine insemination (IUI) cycles in women at risk for ovarian hyperstimulation syndrome (OHSS) when final follicle maturation was induced using a gonadotropin-releasing hormone (GnRH) agonist. MATERIALS AND METHODS: Thirty-three women presenting with a history of cancelled ovarian stimulation for fear of OHSS, underwent repeat gonadotropin ovarian stimulation for IUI. They were all found to be at high-risk for OHSS once more, and were counseled to receive a GnRH agonist to trigger final follicle maturation before insemination. GnRH agonist trigger of ovulation (triptorelin) was given subcutaneously every 12 hours in three repeated doses: 0.3, 0.2, 0.2 mg, respectively. RESULTS: Induction with the agonist was associated with a 30.3% take-home pregnancy rate and 20% miscarriage rate. Multiple pregnancy rates were 26.7%. There were no reported cases of clinically significant moderate/severe ovarian hyperstimulation syndrome. CONCLUSIONS: The use of a GnRH agonist to trigger final follicle maturation in stimulated cycles of hyper responders was associated with a favorable reproductive outcome and no incidence of OHSS. The rate of multiple pregnancies nevertheless was found to be uncontrollably elevated, raising serious concerns regarding the safety of this protocol in standard clinical practice in the context of IUI.

A unilateral twin extrauterine pregnancy occurring in a solitary fallopian tube: therapeutic choices.

A unilateral twin tubal pregnancy occurring in a solitary fallopian tube is presented. The gynecological history was notable for a previous extrauterine pregnancy in the contralateral fallopian tube and reconstructive surgery to the ipsilateral one. Radical total salpingectomy was performed. The rationale for this management is discussed and different therapeutic alternatives presented.

The conventional doses of human chorionic gonadotropins may not always be sufficient to induce ovulation in all women: a reappraisal.

BACKGROUND: Failure of ovulation has occasionally been reported following the administration of conventionally recommended doses of exogenous human chorionic gonadotropins. CASE: A 25-year-old nulliparous woman with polycystic ovary syndrome underwent ovulation induction for primary infertility. Following successful ovarian stimulation, she failed to ovulate during two consecutive cycles in response to human chorionic gonadotropin doses of 5,000 and 10,000 IU. When challenged with a higher than conventional dose (15,000 IU) on the third cycle, she ovulated and conceived. CONCLUSION: Conventional doses of exogenous human chorionic gonadotropins occasionally fail to complete the ovulatory process in some women. Women with polycystic ovary syndrome appear to be particularly susceptible. Routine documentation of ovulation and individualization of the dose of exogenous human chorionic gonadotropins could therefore prove to be useful in some of these women in order to achieve the best treatment outcome.

The SCID mouse: an experimental model for endometriosis.

The purpose of this study was to validate the suitability of the severe combined immunodeficient (SCID) mouse as an experimental model for endometriosis, by defining the morphological and histological features of induced endometrial implants, and characterizing specific biochemical properties of these implants. Human secretory endometrial tissues were injected into the peritoneal cavity of SCID/SCID CB17 mature female mice. Successful peritoneal implantation was observed in 55 of 57 (96.5%) SCID mice and consisted of circumscribed elevated nodules. Haematoxylin-eosin staining of implanting lesions demonstrated the presence of endometrial glandular tissue in a mixed background of stromal and inflammatory cells. When progesterone was administered to mice, epithelial glands underwent well-defined secretory changes. Immunohistochemical analysis using polyclonal human pan-cytokeratin antibodies demonstrated selective positive staining in the glandular epithelium of the human implants with none in the surrounding stroma. In-situ hybridization analysis using complement component 3 cDNA radiolabelled riboprobes yielded significantly more intense signals in glands compared to stroma. As human endometrial implants in SCID mice were shown to retain specific histological, functional and biochemical properties, we conclude that the SCID mouse is an attractive animal model for the study of endometriosis.

The harmonic scalpel: an intraoperative complication.

BACKGROUND: The harmonic scalpel is an ultrasonically activated surgical instrument for tissue dissection. Despite its expanding surgical applications, there are no reports about associated complications. CASE: A 35-year-old woman sustained injury to the sigmoid colon from the use of the harmonic scalpel during laparoscopic lysis of pelvic adhesions. The injury was identified and repaired laparoscopically in a primary fashion with no subsequent sequelae. CONCLUSION: Acoustic energy coupling and overheating of the laparosonic blade extender sheath occur with bending of the instrument. This can happen with steering of the blade extender during laparoscopic surgery and may increase the exposure risk of adjacent tissues to injury.

Suppression and flare regimens of gonadotropin-releasing hormone agonist. Use in women with different basal gonadotropin values in an in vitro fertilization program.

OBJECTIVE: To evaluate the suppression and flare regimens of gonadotropin-releasing hormone agonist (GnRH-a) in ovarian hyperstimulation in women with variable basal gonadotropin values in an in vitro fertilization (IVF) program. STUDY DESIGN: A retrospective study comparing the initiation of GnRH-a in the midluteal phase of the preceding cycle (suppression protocol) and follicular phase of the stimulated cycle (flare protocol) in women with basal follicle-stimulating hormone (FSH) values < 15 mIU/mL and > or = 15 mIU/mL. RESULTS: The pregnancy rate per initiated cycle and implantation rate for women with basal FSH levels > or = 15 mIU/mL were 20.4% and 9.8% in flare GnRH-a cycles and 11.7% and 3.5%, respectively, in suppression GnRH-a cycles. Comparing the percent differences in clinical pregnancy and implantation rates between both protocols for women with different basal FSH values, pregnancy outcome was significantly greater in the flare protocols in women with values > or = 15 mIU/mL (P < .001). Individualization of the stimulation protocol by retrospective sorting of women undergoing IVF with respect to their basal gonadotropin levels significantly improved clinical pregnancy (P < .05) and implantation rates (P < .05) and reduced the cancellation rate (P < .05). CONCLUSION: The flare regimen with GnRH-a is a useful alternative for controlled ovarian hyperstimulation in women with elevated basal FSH values (> or = 15 mIU/mL) undergoing IVF.

Localization of the expression of complement component 3 in the human endometrium by in situ hybridization.

C3 production by the human endometrium has been previously described. The objective of the current study was to localize the site of expression and regulation of the third component of complement, C3, in the endometrium. Eight secretory and eight proliferative archival endometrial samples from hysterectomy and endometrial biopsy specimens were used for in situ hybridization analysis. This analysis was performed with a radiolabeled riboprobe synthesized from a 736-bp template representing sequence 1944-2680 of the human C3 complementary DNA. Duplicate sections were hybridized with sense and antisense riboprobes. Resultant autoradiograms were analyzed qualitatively by light- and darkfield microscopy. In proliferative endometrium, minimal expression of C3 was observed and was limited to a few stromal patches and glands throughout the section. In the secretory samples, prominent C3 expression was observed in both the glands and stroma of the basalis layer. Endometrial lymphocytes did not express C3. Endometrial stromal and glandular cells express the C3 gene. Endometrial lymphocytes did not express C3, but other nondistinct lymphoid elements scattered in the stroma may be expressing C3. There was a visibly more intense expression of C3 in the basalis layer of the secretory endometrium than in proliferative endometrium. The spatial and temporal pattern of C3 expression may have implications in normal menstrual physiology and in the immunological response of the endometrium to the invading trophoblast during placentation.

Alpha 2-macroglobulin production by the human endometrium.

alpha 2-Macroglobulin (A2M) is a broad spectrum plasma protease inhibitor previously described in uterine effluents and recently demonstrated to bind and possibly modulate the functions of cytokines. As cytokines, proteases, and protease inhibitors are important in implantation and endometrial physiology, we sought to investigate and characterize the pattern of production of A2M in the endometrium. Endometrial tissues from different phases of the menstrual cycle were analyzed for A2M production. Tissues were incubated in methionine-free Minimum Essential Medium with [35S]methionine for 12 h at 37 C in 5% CO2. Conditioned media were immunoprecipitated with a polyclonal antibody to human A2M. Recovered proteins were resolved under reducing and nonreducing conditions by 5% sodium dodecyl sulfate-polyacrylamide gel electrophoresis and analyzed by autoradiography. Immunohistochemistry was performed on both cryostat sections of OCT-embedded tissue and formalin-fixed paraffin-embedded tissue. The intensity of staining was evaluated, and a histochemical score was assigned. Comparisons between histochemical scores were performed using the nonparametric Wilcoxon rank sum test. Immunoprecipitation with A2M antibody yielded a single 320-kilodalton protein band under nonreducing conditions and a single 182-kilodalton band under reducing conditions. Both physical and immunological properties of the recovered protein were consistent with A2M. A2M was identified in all endometrial samples and represented approximately 2% of the total radiolabeled proteins produced. Immunohistochemical analysis revealed prominent stromal, but no glandular, staining for A2M throughout the menstrual cycle. The stromal staining in secretory endometrial samples was significantly more intense than that in proliferative samples. In the proliferative phase, staining was more intense in the spongiosum and basalis layers, and less intense in the superficial compactum layer. In the secretory phase, it remained very intense in the spongiosum, but less so in the basalis layer. These findings indicate that A2M is predominantly produced by the stromal component of endometrial tissue. This production is menstrual cycle dependent, with zonal differences in A2M expression within the endometrium, which may indicate a functional significance relevant to the process of implantation that merits further investigation.

Labial edema in pregnancy. A case report.

Edema is a frequently encountered medical sign in pregnancy. Edema confined strictly to the labia, however, is not as common. This report describes severe labial edema in a patient with a twin gestation while on intravenous magnesium sulfate tocolysis. The tocolysis could have initiated the process of labial swelling in the presence of other, predisposing factors.

Ear length: a potential sonographic marker for Down syndrome.

OBJECTIVES: The purpose of this study was to determine if antenatal sonographic determination of fetal ear length is a useful screening method for identification of fetuses with Down syndrome. METHODS: Ear length measurements were recorded in 418 fetuses undergoing ultrasound scanning between 20 and 28 weeks of gestation. Four trisomy 21 and six trisomy 18 fetuses were identified by karyotyping. The relationship between ear length and gestational age in the normal population was determined by linear regression analysis: expected ear length = -6.000 + 1.075 gestational age. The ability of measured-to-expected ear length cut-off ratios to discriminate between affected and non-affected fetuses was assessed. RESULTS: The mean ear length and measured-to-expected ear length ratios were significantly lower in the affected group as compared to the normal one. A measured-to-expected ear length ratio of less than 0.8 was 75.0% sensitive and 98.8% specific in detecting Down syndrome fetuses, and resulted in an 8.5% positive predictive value in the general population. CONCLUSIONS: This preliminary study suggests that antenatal ear length measurements might be a promising sonographic screening method for the detection of Down syndrome in the second trimester of pregnancy.

Postmortem cesarean section following maternal blast injury: case report.

We report a postmortem cesarean section resulting in fetal survival, performed 25 minutes after maternal blast injury. The time interval between cardiopulmonary arrest and delivery, prior maternal health status, and continued cardiopulmonary resuscitation represent important determinants of fetal survival. Improvement in maternal hemodynamic condition may potentially occur following the procedure. Postmortem cesarean section is advised in the event of fatal maternal trauma since it may result in fetal salvage.

High-velocity penetrating wounds of the gravid uterus: review of 16 years of civil war.

OBJECTIVE: To evaluate the value of selective laparotomy in pregnant women with penetrating abdominal injuries. METHODS: A retrospective survey was carried out at our center over 16 years of civil war, extending from 1975 to 1991. Fourteen pregnant women had uterine injuries secondary to high-velocity abdominal penetrating trauma. The corresponding management was evaluated carefully with respect to maternal and fetal outcomes. RESULTS: Two maternal deaths occurred, neither resulting solely from intra-abdominal injuries. Visceral injuries were present when the entrance of the missile was in either the upper abdomen or the back. When the entry site was anterior and below the uterine fundus, visceral injuries were absent in all six women upon surgical exploration. Perinatal deaths occurred in half of the cases and were due to maternal shock or uteroplacental or direct fetal injury. Immediate cesarean delivery was performed because of either limited surgical field exposure, fetal injury, or distress. Three patients explored were managed by delaying delivery. All later delivered vaginally with successful fetal outcomes in all three. CONCLUSION: Selective laparotomy may be considered in pregnant women with anterior penetrating abdominal trauma, as the likelihood of intra-abdominal injuries may be predicted based on the location of the penetrating wound.

Primary malignant lymphoma of the uterine cervix: is radiotherapy the best therapeutic choice for stage IE?

The present report describes a 27-year-old woman diagnosed with Ann Arbor stage IE primary malignant lymphoma of the cervix. Radiation therapy was instituted as conventionally advocated at this early stage of the disease. Despite adequate local tumor response, central nervous system metastasis occurred a few months later. She succumbed to her condition 7 months after initial diagnosis. As occult distant foci may not be amenable to detection by available imaging techniques at the time of initial work-up, combination chemotherapy alone or in conjunction with radiation therapy may be the most appropriate first line of therapy in patients with stage IE primary malignant lymphoma of the cervix.

Imperforate hymen: report of an unusual familial occurrence.

BACKGROUND: Although imperforate hymen occurs in approximately 0.1% of female newborns, familial occurrence of imperforate hymen has been reported only once. CASES: We report two families in which imperforate hymen was diagnosed in three siblings of each family. One family is described in detail; the patients were two postmenarchal young women and one premenarchal girl. CONCLUSION: Imperforate hymen usually occurs sporadically but can be familial. We advise screening all female newborns and children for vaginal patency, especially family members of an affected child. Identification of other families with a similar problem might point to a specific mode of inheritance.

Accessory spleen presenting as adnexal mass.

Pelvic splenic ectopia is a very rare entity, often unsuspected preoperatively. We report a case of an ectopic spleen presenting as an adnexal mass in a middle-aged woman. Diagnosis was achieved intraoperatively, and confirmed pathologically. Pelvic ectopic spleen should be considered in the differential diagnosis of adnexal masses.

Abnormal uterine bleeding in the perimenopause.

Abnormal uterine bleeding is probably one of the most common gynecologic complaints in the perimenopause. It is a significant cause of hysterectomy, which is the second most common surgical procedure performed on women in the United States, and thus is a major health issue. Management consists of a stepwise evaluation of all possible organic causes of uterine bleeding. Advancements in technology have allowed considerable improvements in the resolution of many diagnostic tools. Direct visualization of the uterine cavity is now an invaluable adjunct to blind endometrial sampling. Consequently, therapy can be tailored more appropriately and efficiently, either by newly developed medical strategies or through selective, minimally invasive surgery. In light of these perspectives, some of the recent diagnostic and therapeutic trends in the management of abnormal uterine bleeding in perimenopausal women are presented.