Follicular fluid vascular endothelial growth factor is associated with type of infertility and interferon alpha correlates with endometrial thickness in natural cycle in vitro fertilization.

The aim of this study was to analyse the presence of vascular endothelial growth factor (VEGF) and interferon alpha (IFN-α) in the follicular fluid (FF) and their possible influence, as pro-angiogenic or anti-angiogenic factors, on in vitro fertilization outcome. The concentrations of VEGF and IFN-α were correlated with oocyte and embryo quality, concentrations of hormones in the serum, perifollicular blood flow and endometrial thickness. VEGF was detected in all FF samples (median 706.6 pg/ml, range 182.9-6638 pg/ml). IFN-α was detected in 60% of the samples (median 6.5 pg/ml, range 0-79.4 pg/ml), while in 40% of the samples its levels were below the test detection limit. VEGF and IFN-α concentrations did not correlate with the cause of infertility, concentrations of FSH, LH, E2 and prolactin, oocyte or embryo quality. Significantly higher concentrations of VEGF have been found in women with primary compared with secondary infertility (p = 0.011, Mann Whitney test). The concentrations of VEGF and IFN-α did not correlate with the resistance index (RI) on days of hCG administration, follicular aspiration and embryo transfer. However, the concentrations of IFN-α correlated with endometrial thickness on the day of embryo transfer (Spearman correlation coefficient ρ = 0.4107; P < 0.05) but not on days of hCG administration and follicular aspiration. The mechanism of VEGF association with the previous ability of having a child needs to be clarified in future studies. The results of this study indicate a possible role of IFN-α in pathways of endometrial remodelling.

MANAGEMENT OF RUPTURED CORPUS LUTEUM WITH HEMOPERITONEUM IN EARLY PREGNANCY - A CASE REPORT.

- Rupture of the corpus luteum is a frequent condition in women of reproductive age. Because of abdominal pain accompanied by hemoperitoneum, ruptured corpus luteum can easily be confused with ectopic pregnancy. The management of ruptured corpus luteum depends on the symptoms and laboratory findings, and can be just observation but laparoscopy or urgent laparotomy may also be needed. Although rare, hemoperitoneum following rupture of corpus luteum in early pregnancy should always be considered in the diagnostic process. We present a patient that was admitted to our department with amenorrhea, positive ßhCG and acute abdomen. Emergency laparoscopy was performed but no ectopic pregnancy was found, just blood, coagula and a ruptured corpus luteum. The day after the surgery, intrauterine pregnancy was found on ultrasound and the pregnancy ended with term delivery.

SPONTANEOUS HETEROTOPIC, ECTOPIC CERVICAL AND ECTOPIC TUBAL PREGNANCY - EVER PRESENT DIAGNOSTIC DIFFICULTY: THREE CASE REPORTS.

The incidence of heterotopic/ectopic pregnancy in recent times has increased partly due to the increase in assisted reproductive technologies, whereas such medical cases and cervical pregnancy in particular are extremely rare with spontaneous conception. We report on three patients referred to our department in one week: one patient each with spontaneous heterotopic pregnancy, cervical pregnancy and tubal pregnancy. All of them had conceived spontaneously and were properly diagnosed and treated, however, additional care is needed in diagnosing and managing the potentially fatal consequences of ectopic pregnancy if not recognized early and managed properly, despite its low incidence.

Modification of conservative treatment of heterotopic cervical pregnancy by Foley catheter balloon fixation with cerclage sutures at the level of the external cervical os: a case report.

INTRODUCTION: Conservative treatment of a heterotopic cervical pregnancy was performed with a modification of the fixation of a Foley catheter at the level of the external cervical os, followed by the ligature of the descending cervical branches of the uterine arteries and systemic methotrexate application. CASE PRESENTATION: A 34-year-old Caucasian woman was diagnosed with double gestation after 6 weeks of in vitro fertilization treatment. A gynecological examination and color Doppler ultrasound scan revealed intra-uterine and cervical gestational sacs both containing live fetuses. A Foley catheter balloon was inserted into the cervical canal, inflated and fixed by a cerclage suture at the level of the external cervical os, followed by ligation of the descending cervical branches of the uterine arteries. Systemic methotrexate was applied. Three days after removal of the Foley catheter, an evacuation of the intra-uterine gestational sac was performed. Hemorrhage from the implantation site was controlled immediately and a pregnancy termination was successfully performed. The procedure was uneventful and our patient was discharged with a preserved uterus. CONCLUSIONS: Conservative treatment of cervical pregnancy using a Foley catheter balloon is more efficacious if the Foley catheter balloon is attached in the correct position with a cerclage suture at the level of the external os, followed by ligation of the descending cervical branches of the uterine arteries, thereby exerting maximal pressure on the bleeding vessels.

Ovarian follicular concentration of IL-12, IL-15, IL-18 and p40 subunit of IL-12 and IL-23.

BACKGROUND: The aim of the study was to determine the presence of interleukin (IL)-12, IL-15, IL-18 and p40 subunit of IL-12/IL-23 in follicular fluid from spontaneous cycles and the relation between the concentration of selected cytokines and IVF-embryo transfer outcome. METHODS: IVF-embryo transfer and enzyme immunoassay (EIA) (R&D Systems, Minneapolis, MN, USA and MBL, Nagoya, Japan) were used. RESULTS: Follicular fluid of women included in the IVF-embryo transfer procedure contained common p40 subunit of IL-12/IL-23 (median 70.1 pg/ml), IL-15 (median 1.3 pg/ml) and IL-18 (median 38.2 pg/ml). There was a significant negative correlation between follicular fluid concentrations of IL-15 and IL-18 (R=-0.392, P=0.003). Significantly higher concentrations of common p40 subunit of IL-12/IL-23 (median 79.8 pg/ml) were found in the follicular fluid taken from follicles containing oocytes, when compared with those without an oocyte (median 44.5 pg/ml, P=0.006). Patients who achieved clinical pregnancy had significantly decreased concentration of IL-15 (median 0.8 pg/ml) compared with patients without successful IVF-embryo transfer outcome (median 1.4 pg/ml, P=0.047). CONCLUSION: Follicular fluid collected from spontaneous cycles contains detectable levels of p40 subunit of IL-12/IL-23, IL-15 and IL-18. Increased concentrations of p40 subunit of IL-12/IL-23 in follicles containing oocytes suggest an important role of this cytokine in reproduction. Possible negative value of IL-15 as a predictor of IVF-embryo transfer success remains to be determined.

Pericentric inversion of chromosome 2 in a patient with the empty follicle syndrome: case report.

The empty follicle syndrome (EFS) is defined as a lack of retrieved oocytes from follicles, at the time of repeated aspiration and flushing, following ovulation induction. The actual mechanism responsible for the EFS is still unknown. The aim of this study was to offer more information regarding the possible connection of this syndrome with pericentric inversion of chromosome 2. We give a case report of a patient who had multiple failed IVF attempts, due to the absence of oocyte and granulosa cells in the follicular fluid, following oocyte retrieval in both stimulated and natural cycles. Chromosomal analysis showed the presence of a pericentric inversion of chromosome 2: 46,XX,inv(2)(p11q21) in the female partner karyotype, while the male partner had a normal karyotype. Our case showed possible genetic factor influence in the aetiology of EFS.

Long-term treatment with vaginal estradiol tablets--an impact on uterine artery blood flow.

OBJECTIVE: We investigated, using color Doppler ultrasound, possible detectable blood changes of prolonged treatment with 17-beta-estradiol tablets on uterine artery blood flow, in a cohort of low risk postmenopausal women. METHODS: 39 postmenopausal women, who were taking local estrogen therapy for at least 6 months, were examined in the study group. Forty-two women who never used hormone replacement therapy consisted a control group. They were examined with color Doppler ultrasound and the pulsatility index of the uterine artery was measured. The groups were divided into three subgroups (the age, the duration of the postmenopause, and the duration of the treatment) and the data were compared among groups and within subgroups. RESULTS: The overall mean age of the patients was 66 years, the mean duration of the postmenopause was 15 years, the overall mean PI was 1.96 +/- 0.90, and the mean duration of taking vaginal estradiol tablets was 1.97 years for the study group; and 64 years, 13 years and 2.88 +/- 0.96 for the control group, respectively. There was a difference in the mean PI among groups. No significant differences in pulsatility index values in the subgroups were found. CONCLUSION: Long-term treatments with vaginal estradiol tablets in low risk women causes lowering of the uterine artery PI values compared to the women who are not receiving hormone replacement therapy.

Influence of hormonal stimulation on in vitro fertilization/embryo transfer outcome.

OBJECTIVE: To compare efficacy and efficiency of ovarian stimulation therapy. STUDY DESIGN: Retrospective study compares ovarian response as number of retrieved oocytes, fertilization rates, endometrial patterns, number of pregnancies and pregnancy rates to different stimulation protocols. RESULTS: The least number of cancelled cycles was in long protocols with buserelin. There was no difference in overall number of retrieved oocytes between the rFSH and HMG protocols, but 75% of the patients undergoing both protocols had higher number of oocytes after rFSH. The highest pregnancy rate (35.13%) was with rFSH. There was no statistical correlation between endometrial pattern and type of protocol used. Data showed the 9 mm cut-off value for endometrial thickness, and RI = 0.58 for subendometrial blood flow between the pregnant and non-pregnant group of patients. Nitriderm patches significantly decreased (P < 0.05) subendometrial RI of the patients with impaired uterine perfusion, increased endometrial thickness and achieved better morphology. CONCLUSIONS: These findings demonstrate that rFSH alone and in long protocol gives better results in wide patient population. Nitriderm patches seem to have good impact on pregnancy rate, but further studies are necessary before making any statements.

Vaginal aplasia associated with anatomically and functionally normal uterus.

Maldevelopment of the vagina is usually combined with aplasia/hypoplasia of the uterus. Complete vaginal aplasia with a normally developed uterus and cervix is an extremely rare form of developmental failure. The accepted treatment for this kind of maldevelopment is hysterectomy plus creation of a neovagina. We present the case of 12-year-old girl with isolated complete vaginal aplasia. After the creation of a vagina during a first procedure and lysis of pericervical adhesions with implantation of skin graft in a second she now has regular menstrual bleeding.

In vitro fertilization in spontaneous cycles--our experience.

OBJECTIVE: To study the efficacy of a simple protocol of natural cycle in vitro fertilization. METHOD: A retrospective study of 59 natural treatment cycles in 37 infertile couples with previous unsuccessful attempts of conventional in vitro fertilization. RESULTS: In 24% of cycles, the aspiration was cancelled because of inadequate visualization of follicles or because of preterm ovulation. Aspiration was performed in 45 cycles with oocyte retrieval of 82% per aspiration. Embryo transfer was performed in 30 cycles, pregnancy rate per pick-up was 15%. CONCLUSION: In vitro fertilization in a natural cycle is a simple, relatively cheap and comfortable procedure with reasonable results and can be offered to patients scheduled not only for in vitro fertilization because of tubal factor but also to patients with endometriosis or unexplained infertility.