Ureter Injury in Laparoscopic Para-Aortic Lymphadenectomy for Endometrial Cancer by the Transperitoneal Approach.

The patient was 66 years old, had three pregnancies and two deliveries, and was menopausal at the age of 51. She had irregular bleeding and was found to have a chicken-egg-sized uterus and a thickened endometrium (23 mm). She underwent laparoscopic surgery for uterine endometrial cancer (endometrioid carcinoma G1, stage IB). Laparoscopic simple hysterectomy, bilateral adnexectomy, pelvic lymph node dissection, para-aortic lymph node dissection, and partial omentectomy were performed using the transperitoneal approach (TPA). The patient was obese, with a height of 148 cm, a weight of 68 kg, and a body mass index of 31 kg/m2. She had a large amount of visceral fat, which made it difficult to expand the surgical field during para-aortic lymph node dissection. A laparoscopic fan retractor (EndoRetract II, Medtronic) was used to lift the intestinal tracts and expand the field of view. It broke the fat around the left kidney, and the exposed left ureter was heat-damaged using a vessel sealing device (LigaSure, Medtronic). Postoperatively, a left ureteral stent was placed, and continuous urine draining into the retroperitoneum was performed. To prevent injury to the left ureter, the left ovarian vein branching from the left renal vein should be exposed as a landmark before the left ureter running parallel to it is isolated. It is essential that the fat around the left kidney is not broken during this operation. The left iliopsoas muscle should be exposed, and using this as a base, the left ovarian vein, left ureter, and left perirenal fat should be compressed and moved to the left side using a fan retractor to ensure a safe operation.

Ureter Injury in Total Laparoscopic Hysterectomy.

Objective: To identify surgical manipulations that caused ureter injury during total laparoscopic hysterectomy (TLH) and evaluate the surgical manipulations to identify ways to prevent such injury. Patients and Methods. This single-center, cross-sectional study included 1135 cases of TLH performed for benign diseases from January 2009 to December 2021. Seven cases (0.6%) that needed ureteral stent placement intra- or postoperatively for ureter injury were included. We identified the surgical manipulations that caused ureter injury from surgical videos. Results: Two cases had adhesions around the bladder pillar, and the ureter sustained a thermal injury during the cardinal ligament transection. One case had severe endometriosis, and the ureter was bluntly damaged when the adhesion was released. In one case, the ureter was thermally damaged during bipolar hemostasis for uterine artery bleeding. In two cases, the obliterated umbilical artery was mistaken for the ureter, and the real ureter was injured. In one case, ureteral peristalsis was inhibited by a pelvic abscess caused by postoperative infection. Conclusion: To prevent ureter injury during TLH, the ureter should be isolated in case of severe adhesion. Moreover, the following could be considered: (1) expand Okabayashi's pararectal space lateral to the uterosacral ligament, (2) perform dissection sharply using a monopolar or scissors forceps when releasing adhesion, (3) clarify the anatomy around the ureter for cases needing hemostasis, (4) repeatedly confirm the ureter with its peristalsis even after its isolation, (5) for severe adhesion cases, reduce infection risk by drain placement and administering antibiotics, and (6) use a delineator cup.

Laparoscopic intervention for solid pelvic tumours in Mayer-Rokitansky-Küster-Hauser syndrome: a case of bilateral uterine adenomyomas of the rudimentary uterus.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a condition caused by Müllerian anomalies, is characterised by congenital vaginal aplasia and a rudimentary uterus. Case reports concerning uterine fibroids associated with MRKH syndrome are limited, and differentiating between uterine fibroids and ovarian solid tumours prior to surgical intervention is often challenging. Here, we present the case of a patient with MRKH syndrome and asymptomatic bilateral pelvic solid tumours located close to both ovaries. Based on intraoperative and histopathological findings, the tumours were diagnosed as adenomyomas of the rudimentary uterus. This is the first reported case of a uterine adenomyoma associated with MRKH syndrome. Moreover, our report highlights the fact that diagnostic laparoscopy is a valuable method to evaluate pelvic tumours in MRKH syndrome.

Gastrointestinal Stromal Tumor with Repeated Multiple Cerebral Infarction Mimicking Ovarian Cancer with Trousseau's Syndrome.

We report a case of gastrointestinal stromal tumor (GIST) with repeated multiple cerebral infarctions mimicking ovarian cancer. A 79-year-old postmenopausal woman had multiple cerebral infarctions with a giant pelvic tumor detected by computed tomography. Ovarian cancer with Trousseau's syndrome was suspected. Through laparoscopic biopsy on the tumor surface, she was diagnosed with left ovarian fibrosarcoma; although, the abdominal cavity could not be observed appropriately. Ovarian fibrosarcoma is an extremely rare tumor and still has no adequate treatment strategy. Complete resection was planned. The tumor was extremely fragile, and gelatinous that it easily bled. Meanwhile, the uterus and bilateral ovaries and fallopian tubes were all normal. The tumor invaded only the peritoneum near the left sacral uterine ligament and sigmoid colon, with no peritoneal dissemination. To completely remove the tumor, we performed total hysterectomy with bilateral salpingo-oophorectomy and omentectomy and sigmoidal and rectal resection with colostomy. Despite resuming her anticoagulant therapy on postoperative day 4, she had recurrent multiple strokes. On histopathological examination, tumor showed spindle cell proliferation with severe atypia, increased mitotic activity, and widespread necrosis. Immunohistochemical studies showed positive staining for c-kit, CD34, and DOG1. Thus, she was diagnosed with GIST. This case was rare and highly malignant, with a high risk of recurrence of GIST because of a giant ruptured tumor that had a mitotic activity of 36/10 high-power fields from the sigmoid colon. Multiple cerebral infarctions mimicking ovarian cancer recurred. Therefore, preoperative diagnosis of an atypical GIST was extremely difficult.

A case of problems in supporting a patient after Y-chromosome long arm microdeletion testing at a Japanese general hospital.

There are only few reports on the problems faced post-Y-chromosome microdeletion tests that decide the use of micro testicular sperm extraction. We report a case wherein we faced issues in supporting a patient post-testing. One patient with azoospermia factor c (AZFc) deletion gave birth to a baby boy, who could have inherited the AZFc deletion; however, we could not inform the young patient. Therefore, it is necessary to establish a post-testing support system for patients and infants.

Robot-assisted laparoscopic hysterectomy for endometrial cancer in a patient with Herlyn-Werner-Wunderlich syndrome.

Herlyn-Werner-Wunderlich syndrome, a rare Mullerian duct anomaly, includes a triad of uterine didelphys, obstructed haemivagina and ipsilateral renal agenesis. A 58-year-old woman with Herlyn-Werner-Wunderlich syndrome, reported of recurrent genital bleeding for 9 years, was finally diagnosed with endometrial cancer. She had a history of vaginal septum resection and nephrectomy of atrophic right kidney. MRI demonstrated uterine didelphys, a tumour filling the left uterus and a cyst on the right lateral side of the uterus. Robot-assisted hysterectomy, including bilateral salpingo-oophorectomy and pelvic lymphadenectomy, was performed. As the cyst communicated with the right cervix, but not with the urinary tract, a Gartner duct cyst was diagnosed. Uncertain diagnosis and delay of treatment in endometrial cancer may occur in patients with Herlyn-Werner-Wunderlich syndrome. We should preoperatively fully evaluate the anatomy of the uterus and surrounding tissues and plan surgical procedures, especially in patients with urogenital malformations.

Abnormal Urine Outflow from the Ureteral Orifice on Cystoscopy Following Vaginal Stump Suture in Total Laparoscopic Hysterectomy.

OBJECTIVES: Ureteral injuries may occur subsequent to abdominal or laparoscopic hysterectomy. In total laparoscopic hysterectomy (TLH), we usually check for ureteral damage by confirming urinary outflow from the bilateral ureteral orifices by cystoscopy after vaginal stump suture. In this work, we investigated the causes of urine outflow disruption after TLH. MATERIALS AND METHODS: We conducted a retrospective review of all TLHs performed for benign diseases at our hospital from February 2012 to March 2016. There were 11 cases with no or poor urine outflow from the ureteral orifice after vaginal stump suture. For these cases, we assessed the treatment to recover urine outflow and examined the cases with intraoperative manipulation. EZR version 1.25 was used for statistical analysis. Correlation coefficients were calculated with Spearman's rank correlation coefficient test. RESULTS: The abnormality was on the right and left sides in seven and four cases, respectively. In all cases, apart from one, urine outflow was recovered by removing the sutures at the affected side, where the initial suture had included a small amount of the connective tissue near the urinary bladder. It was inferred that ureteral deviation due to vaginal stump sutures that picked up the connective tissue near the ureter caused ureteral peristaltic disorder and abnormal ureteral orifice outflow. CONCLUSION: TLH without ureter isolation requires sufficient separation of the bladder from the anterior vaginal wall and careful vaginal stump suture without involving the bladder-side tissue to avoid ureteral injury.

A Case of Trousseau's Syndrome Accompanying Ovarian Cancer with Widespread Thromboembolisms.

The patient was a 41-year-old woman, gravida 0. She had no notable medical history. Laparoscopic right salpingo-oophorectomy and left cystectomy were performed for bilateral ovarian endometriomas, which were both pathologically diagnosed as benign. Six months later, she presented with left lower abdominal pain and expressive aphasia. Examination revealed multiple cerebral infarctions and pulmonary embolism. The patient was diagnosed with Trousseau's syndrome secondary to ovarian cancer, and anticoagulant therapy was initiated. Despite treatment, she developed visual field loss due to occlusion of the left retinal artery; dizziness due to cerebellar infarction and myocardial infarction; and right hemiplegia due to new cerebral infarction. She received chemotherapy (two courses of paclitaxel and carboplatin), which did not improve her condition, and died two months after onset. An autopsy revealed that her left ovary was enlarged to a size of 12 cm and an endometrioid carcinoma G2 was identified. Ovarian cancer had spread throughout the abdominal cavity, and a large amount of pleural and ascites fluid was present. Multiple thrombi were found in bilateral pulmonary arteries and bilateral common iliac veins. There was a 2.5 cm thrombus in the left ventricle apex, and the anterior descending branch was obstructed by thrombus with recanalization.

Acute Abdomen due to Mutual Tangle of Two Small Paratubal Cysts.

A 30-year-old woman (gravida 0) visited our hospital with a complaint of right lower abdominal pain. Transvaginal ultrasonography revealed a 5-cm swollen right ovary, which was suspected to be a mature cystic teratoma. Pelvic examination revealed moderate pain. Contrast-enhanced computed tomography showed a 44-mm cystic mass containing fat and calcified material in the right pelvis. Since torsion was suspected, emergent laparoscopic surgery was performed. Intraoperative findings were a swollen right ovary without torsion or congestion. Two small pedunculated 1- and 2-cm diameter paratubal cysts that grew from almost the same place of the ampulla of the right fallopian tube were observed. The thin stalk of the 1-cm paratubal cyst was entangled around the stalk of the 2-cm paratubal cyst, with its head congested. Through a small abdominal laparoscopic incision, the tumor of the right ovary and the two paratubal cysts were excised. Histopathological examination revealed that the right ovarian tumor was a mature cystic teratoma, and the two paratubal cysts had no malignancy. This case showed that only a 2-cm tumor with congestion caused the acute abdomen.

Possible involvement of CD10 in the development of endometriosis due to its inhibitory effects on CD44-dependent cell adhesion.

A reduced response to progesterone in the eutopic endometrium with endometriosis and in endometriotic tissues is considered to be the underlying factor for endometriosis. CD10 is known to be expressed by endometrial and endometriotic stromal cells and may be induced by progestins, although the function of CD10 is not fully revealed in endometrial or endometriotic tissues. In the current study, the expression of CD10 was significantly increased by treatment of the cells with progesterone, 17ß-estradiol, and dibutyryl cyclic adenosine monophosphate (cAMP) in the endometrial stromal cells. On the other hand, the expression of CD10 following treatment with progesterone, 17ß-estradiol, and dibutyryl cAMP was not significantly increased in endometriotic stromal cells. The adhesion assay for endometrial and endometriotic stromal cells to hyaluronan using 5- or 6-(N-succinimidyloxycarbonyl)-fluorescein 3', 6'-diacetate-labeled cells demonstrated that the CD44-dependent adhesion of stromal cells was inhibited by CD10. As far as the induction of CD10 is concerned, the effect of progesterone was different between endometrial stromal cells and endometriotic stromal cells. CD10 might be involved in the development of endometriosis due to its influence on CD44-dependent cell adhesion.

A proteomic analysis of human follicular fluid: comparison between fertilized oocytes and non-fertilized oocytes in the same patient.

PURPOSE: Human follicular fluid constitutes the microenvironment of follicles and includes various biological active proteins that can affect follicle growth and oocyte fertilization. Conducting proteomic evaluations of human follicular fluid may be helpful for identifying potential biomarkers possibly possessing a predictive value for oocyte quality and the success of in vitro fertilization. METHOD: We performed proteomic profiling of human follicular fluids containing oocytes that were fertilized and resulted in pregnancy and follicular fluids containing oocytes that were not fertilized in the same patients undergoing intracytoplasmic sperm injection using the LTQ Orbitrap coupled with liquid chromatography-tandem mass spectrometry (LC/MS/MS) analyses. RESULTS: We identified a total of 503 proteins in human follicular fluids containing fertilized and non-fertilized oocytes obtained from 12 patients. We also found that 53 proteins exhibited significantly different spectral counts between the two groups, including heparan sulfate proteoglycan perlecan, which showed significant upregulation in the follicular fluids containing fertilized oocytes in comparison with that observed in the follicular fluids containing non-fertilized oocytes. CONCLUSION: Our results suggest a possibility that proteins identified by LC/MS/MS in follicular fluid might not only be involved in folliculogenesis, but also function as biomarkers possessing predictive potential for oocyte maturation and the success of IVF when their expression levels are significantly different between fertilized and non-fertilized oocytes, although no distinctive biomarkers were identified in the current study.

Met is the most frequently amplified gene in endometriosis-associated ovarian clear cell adenocarcinoma and correlates with worsened prognosis.

Clear cell adenocarcinoma of the ovary (OCC) is a chemo-resistant tumor with a relatively poor prognosis and is frequently associated with endometriosis. Although it is assumed that oxidative stress plays some role in the malignant transformation of this tumor, the characteristic molecular events leading to carcinogenesis remain unknown. In this study, an array-based comparative genomic hybridization (CGH) analysis revealed Met gene amplification in 4/13 OCC primary tumors and 2/8 OCC cell lines. Amplification of the AKT2 gene, which is a downstream component of the Met/PI3K signaling pathway, was also observed in 5/21 samples by array-based CGH analysis. In one patient, both the Met and AKT2 genes were amplified. These findings were confirmed using fluorescence in situ hybridization, real-time quantitative PCR, immunoblotting, and immunohistochemistry. In total, 73 OCC cases were evaluated using real-time quantitative PCR; 37.0% demonstrated Met gene amplification (>4 copies), and 8.2% had AKT2 amplification. Furthermore, stage 1 and 2 patients with Met gene amplification had significantly worse survival than patients without Met gene amplification (p<0.05). Met knockdown by shRNA resulted in reduced viability of OCC cells with Met amplification due to increased apoptosis and cellular senescence, suggesting that the Met signaling pathway plays an important role in OCC carcinogenesis. Thus, we believe that targeted inhibition of the Met pathway may be a promising treatment for OCC.

Sphingosine-1-phosphate inhibits H2O2-induced granulosa cell apoptosis via the PI3K/Akt signaling pathway.

OBJECTIVE: To investigate the protective effect of sphingosine-1-phosphate (S1P) against H(2)O(2)-induced apoptosis in human granulosa cell cultures with freshly harvested granulosa cells. DESIGN: Experimental study. SETTING: Academic medical center for reproductive medicine. PATIENT(S): Cultures of primary granulosa cells isolated from women undergoing in vitro fertilization (IVF). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Cell apoptosis and Western blot analysis of signaling pathway proteins. RESULT(S): We found that S1P (1 and 10 mM) statistically significantly decreased granulosa cell apoptosis after H(2)O(2) treatment. The decreased cell apoptosis induced by S1P was abolished after treatment with VPC23019, an inhibitor of S1P1 and S1P3 receptors, W146, an inhibitor of S1P1 receptors, and CAY10444, an inhibitor of S1P3 receptors. A Western blot analysis revealed that the level of phospho-Akt increased and peaked at 10 minutes after 10 mM S1P exposure. CONCLUSION(S): Treatment with S1P can inhibit the apoptosis of granulosa cells in response to oxidative stress induced by H(2)O(2). The protective effect of S1P is mediated by activating the PI3K/Akt pathway, and the antiapoptotic effect of S1P is mainly mediated through the S1P1 and S1P3 receptor.

The ferroimmunomodulatory role of ectopic endometriotic stromal cells in ovarian endometriosis.

OBJECTIVE: To understand the role of ectopic endometriotic stromal cells in ovarian endometriosis (OEM) and the associated risks for infertility and carcinogenesis. DESIGN: Analyses of secreted proteins and gene expression using immortalized eutopic/ectopic endometrial(-otic) stromal cells from OEM. SETTING: University. PATIENT(S): Women with and without OEM. INTERVENTION(S): Samples of endometrial(-otic) tissue from women with or without OEM. MAIN OUTCOME MEASURE(S): Immunohistochemical analysis of oxidative stress in OEM, gene expression profiles, and the identification of secreted proteins by mass spectrometry in immortalized endometrial(-otic) stromal cells. RESULT(S): 4-Hydroxy-2-nonenal-modified proteins and carboxymethyllysine were abundant in the stroma, rather than epithelia, of OEM patients, indicating the presence of oxidative stress. Immortalized ectopic endometriotic stromal cells exhibited high IRP1/IRP2/HIF-1ß expression and contained lower amounts of iron and copper than their eutopic counterparts. Expression profiles, in combination with protein identification, revealed that complement component 3 (C3) and pentraxin-3 (PTX3) are the major proteins secreted from immortalized ectopic endometriotic stromal cells. Complement-3/PTX3 promoted the secretion of various cytokines by THP1 macrophage cells and thus supported M1 differentiation. CONCLUSION(S): Immortalized ectopic endometriotic stromal cells in OEM predominantly secrete C3 and PTX3 and exhibit a differential regulation of iron metabolism.

Chemical anchoring of lauryl methacrylate-based reversed phase monolith to 1/16″ o.d. polyetheretherketone tubing.

In this paper, we describe a method for the preparation of easy-to-use reversed-phase monolithic microbore columns. Polyetheretherketone (PEEK) tubing with an outer diameter of 1/16″ and an inner diameter of 1.0 mm was used as a column housing (empty column), and in it lauryl methacrylate (LMA) was copolymerized with ethylene dimethacrylate (EDMA). In order to chemically anchor the polymer monolith to the tube wall, the inner wall surface was pretreated by the following two-step procedure. (1) 50% sulfuric acid was filled into the PEEK tubing and left to stand for 6 h to generate sulfonate groups on the surface. (2) After washing with Milli-Q water, the sulfonated PEEK surface was brought into contact with 1 M glycidyl methacrylate in dichloromethane (or acetone) at 40°C for 4 h to introduce methacryloyl groups via the reaction of sulfonate groups and epoxy groups. Mechanical strength and column efficiency of the resulting monoliths were evaluated through the separation of a series of alkylbenzenes in acetonitrile-water (50:50, v/v) eluent over the flow rate range of 50-750 µL/min (corresponding to 1.7-25.5 mm/s). The poly(LMA-co-EDMA) monolith provided acceptable column efficiency of 2000 theoretical plates/10 cm (HETP value of 50 µm) for amylbenzene (separation factor k=40) and low flow resistance of 0.5 MPa/10 cm at a normal flow rate of 50 µL/min. The methacryloylated PEEK tubing tightly held the monolith, and the monolithic column exhibited good pressure resistance up to 15 MPa, allowing rapid separation at a 15-20 fold higher flow rate than normal.

Establishment of a human nonluteinized granulosa cell line that transitions from the gonadotropin-independent to the gonadotropin-dependent status.

The ovary is a complex endocrine organ responsible for steroidogenesis and folliculogenesis. Follicles consist of oocytes and two primary steroidogenic cell types, the granulosa cells, and the theca cells. Immortalized human granulosa cells are essential for researching the mechanism of steroidogenesis and folliculogenesis. We obtained granulosa cells from a 35-yr-old female and immortalized them by lentivirus-mediated transfer of several genes so as to establish a human nonluteinized granulosa cell line (HGrC1). We subsequently characterized HGrC1 and investigated its steroidogenic performance. HGrC1 expressed enzymes related to steroidogenesis, such as steroidogenic acute regulatory protein, CYP11A, aromatase, and gonadotropin receptors. Stimulation with FSH increased the mRNA levels of aromatase, which consequently induced the aromatization of androstenedione to estradiol. Activin A increased the mRNA levels of the FSH receptor, which were synergistically up-regulated with FSH stimulation. HGrC1 also expressed a series of ligands and receptors belonging to the TGF-ß superfamily. A Western blot analysis showed that bone morphogenetic protein (BMP)-4, BMP-6, and BMP-7 phosphorylated small mother against decapentaplegic (Smad)1/5/8, whereas growth differentiation factor-9 phosphorylated Smad2/3. BMP-15 and anti-Müllerian hormone phosphorylated Smad1/5/8 while also weakly phosphorylating Smad2/3. These results indicate that HGrC1 may possess the characteristics of granulosa cells belonging to follicles in the early stage. HGrC1 might also be capable of displaying the growth transition from a gonadotropin-independent status to gonadotropin-dependent one.

Expression and localization of CXCL16 and CXCR6 in ovarian endometriotic tissues.

PURPOSE: Inflammatory mediators, including chemokines, may play crucial roles in the development of endometriosis. Therefore, we investigated the expression and localization of CXCL16 and its receptor, CXCR6, in ovarian endometriotic tissues. We also examined whether CXCL16 induces IL-8 production in endometriotic stromal cells. METHODS: We performed immunohistochemical and Western blotting analyses of in vivo and in vitro samples. IL-8 production was assayed using an ELISA. RESULTS: Both CXCL16 and CXCR6 were expressed by endometriotic epithelial cells and stromal cells, but not normal ovarian stroma. A Western blotting analysis using primary cultured endometriotic stromal cells showed a constant expression of CXCL16 and CXCR6 in the proliferative phase, secretory phase and during gonadotropin-releasing hormone agonist therapy. CXCL16 induced IL-8 production in several endometriotic stromal cells in vitro. CONCLUSIONS: CXCL16 and CXCR6 might be involved in the pathophysiology of endometriosis through regulation of the inflammatory response.

Preparation and characterization of lauryl methacrylate-based monolithic microbore column for reversed-phase liquid chromatography.

Poly(lauryl methacrylate-co-ethylene dimethacrylate) monoliths were in situ synthesized within the confines of a silicosteel tubing of 1.02 mm i.d. and 1/16" o.d. for microbore reversed-phase HPLC. In order to obtain practically useful monoliths with adequate column efficiency, low flow resistance, and good mechanical strength, some parameters such as total monomer concentration (%T), cross-linking degree (%C) and polymerization temperature were optimized. High-efficiency monoliths were successfully obtained by thermal polymerization of a monomer mixture (40%T, 10%C) with a binary porogenic solvent consisting of 1-propanol and 1,4-butandiol (7:4, v/v) at a high temperature of 90 °C. The morphology and porous structure of the resulting monoliths were assessed by scanning electron microscope (SEM) and inverse size exclusion chromatography (ISEC), while the column performance was evaluated through the separations of a series of alkylbenzenes in acetonitrile-water (50:50, v/v) eluent. At a normal flow rate of 50 µL/min (corresponding to 1.66 mm/s), the optimized monolithic columns typically exhibited theoretical plate numbers of 6000 plates/10 cm-long column for amylbenzene (k>40), and the pressure drop was always less than 1 MPa/10 cm. The monoliths, which were chemically anchored to the tube inner wall surface using a bifunctional silylation agent, exhibited adequate mechanical strength of up to 12-13 MPa, and were properly operated at 10 times higher flow rate than normal, reducing the separation time to one tenth. The lauryl methacrylate-based monolithic column was applied to a rapid and efficient separation of ten common proteins such as aprotinin, ribonuclease A, insulin, cytochrome c, trypsin, transferrin, conalbumin, myoglobin, ß-amylase, and ovalbumin in the precipitation-redissolution mode. Using a linear CH(3)CN gradient elution at a flow rate of 500 µL/min (10-times higher flow rate), 10 proteins were baseline separated within 2 min.

Successful fertility management of a patient with factor V deficiency: planned transfusion of fresh frozen plasma under infertility treatment.

OBJECTIVE: To report the case of a patient with factor V deficiency who achieved pregnancy with the planned transfusion of fresh frozen plasma (FFP) while monitoring follicle development and ovulation induction using gonadotropin. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 28-year-old nulliparous female. INTERVENTION(S): Medical management including infertility treatment. MAIN OUTCOME MEASURE(S): Clinical follow-up. RESULT(S): A patient with factor V deficiency experienced repeated ovulation-related hemoperitoneum following the withdrawal of oral contraceptive pills. The monitoring of follicle development and ovulation induction using gonadotropin followed by FFP transfusion was useful to avoid hemoperitoneum. Pregnancy was achieved within a relatively short period using intrauterine insemination. CONCLUSION(S): Planned prophylactic FFP administration and intervention with infertility treatment might be useful to minimize the risk of ovulation-related hemoperitoneum in patients with factor V deficiency.