An algorithm for the pre-operative differentiation of benign ovarian tumours based on magnetic resonance imaging interpretation in a regional core hospital: A retrospective study.

Objective: For selecting minimally invasive surgery (i.e. laparoscopic ovarian cystectomy) for treating ovarian tumours (OTs) in premenopausal patients, the pre-operative differentiation of benign ovarian tumours (Be-OTs) based on magnetic resonance imaging (MRI) interpretation is important. This paper describes the authors' 8-year experience of approximately 1000 OT cases, and provides information about a diagnostic algorithm to help other hospitals. Study design: The medical records of 901 patients aged < 50 years with OTs from 1 January 2015-31 March 31 2023 were reviewed. First, the accuracy of pre-operative differentiation between Be-OTs and borderline/malignant ovarian tumours (Bo/Ma-OTs) was compared in each type of OT. Second, to identify the factors influencing differentiation between Be-OTs and Bo/Ma-OTs in 164 serous/mucinous ovarian tumours (SM-OTs), a multi-variate logistic regression analysis was performed to assess the effect of 13 factors, including MRI findings, OT size and tumour markers. Results: In the comparison of diagnostic accuracy of pre-operative MRI for each OT type, accuracy was found to be notably high for ovarian endometrial cyst (OEC) (n = 409), ovarian mature cystic teratoma (OMCT) (n = 308), ovarian endometrioid adenocarcinoma (OEA) (n = 6) and ovarian clear cell adenocarcinoma (OCCA) (n = 14). On the other hand, discrepancies between MRI and pathological findings often occurred in SM-OTs, including ovarian serous cystadenoma (n = 86), ovarian mucinous adenocarcinoma (n = 61), ovarian serous adenocarcinoma (n = 12) and ovarian mucinous adenocarcinoma (n = 5). In the multi-variate logistic regression analysis of the latter 164 patients, in addition to MRI findings, OT size and carbohydrate antigen 125 also had an effect to some extent. The combination of MRI interpretation and OT size may enhance differentiation of Be-OTs and Bo/Ma-OTs. Conclusions: Among four types of OTs (OEC, OMCT, OEA and OCCA), MRI interpretation was able to differentiate between Be-OTs and Bo/Ma-OTs almost perfectly. Additionally, to mitigate the difficulty in differentiating SM-OTs, OT size may be useful in combination with MRI findings, although further accumulation and analysis of OT cases is needed.

Obvious advantage of vaginal natural orifice transluminal endoscopic surgery hysterectomy against total laparoscopic hysterectomy in small uterus patients and the future prospects at a regional core institution: A retrospective study.

Objective: Owing to the combination of benefits, including permanent visual guidance and no abdominal skin incision, vaginal natural orifice transluminal endoscopic surgery hysterectomy (vNOTES-H) is currently widely used. However, the introduction of vNOTES-H has been delayed in many Japanese regional core hospitals because of its specific device and skill requirements. Therefore, the characteristics and advantages should be explained for the widespread use of this technique. Study design: We reviewed the medical records of 17 patients with vNOTES-H and 94 patients with total laparoscopic hysterectomy (TLH) from January 1, 2015 to December 31, 2022. In this analysis, to compare the results of vNOTES-H to TLH, we excluded certain patients with a relatively heavy uterus (>255 g) and the presence of abdominal adhesions. In this report, first, the characteristics of the vNOTES-H procedures using a transvaginal access platform are explained by referring to one representative patient. Second, the patient characteristics of the vNOTES-H and TLH groups, including operation time and blood loss amount, were compared. Then, to detect the influence of vNOTES-H on the difficulty of operation among all 111 patients, we performed a multivariate logistic regression analysis to assess the influence of each of 9 factors, including "vNOTES-H", "Advanced age", "High BMI", "3 parity", "Gynaecological operation history", "Adenomyoma", "Large leiomyoma", "Heavy uterus" and "Large uterus", on the two indexes, including "Short time operation" and "Massive blood loss". Results: In the simple comparison between the groups with vNOTES-H and TLH, the operation time in the former group was significantly shorter than in the latter group, although other factors did not show significant differences, including blood loss amount. Moreover, in the multivariate logistic regression analysis of all 111 patients, the "vNOTES-H" factor showed a significantly high possibility of "short time operation", although no factor, including "vNOTES-H", showed a significant influence on "massive blood loss". Conclusions: vNOTES-H showed advantages in terms of operation time without increasing blood loss for patients with a relatively small uterus. However, to expand the selection for vNOTES-H, we should accumulate further patients and perform more analyses.

Desmoid Tumor Mimicking Port Site Metastasis after Laparoscopic Surgery for Endometrial Cancer.

Desmoid tumors are rare; however, they sometimes form in the abdominal wall after surgery or trauma. We report a case of desmoid tumors in the abdominal wall mimicking port-site metastasis after laparoscopic surgery for endometrial cancer. A 53-year-old woman with familial adenomatous polyposis presented to our hospital with vaginal bleeding and was diagnosed with endometrial cancer. We performed a total laparoscopic hysterectomy and began observation. Two years after surgery, follow-up computed tomography revealed three nodules with a size of approximately 15 mm in the abdominal wall at the trocar sites. Tumorectomy was performed because endometrial cancer recurrence was suspected, but desmoid fibromatosis was finally diagnosed. This is the first report of desmoid tumors at the trocar site after laparoscopic surgery for uterine endometrial cancer. Gynecologists should be aware of this disease because differentiating it from metastatic recurrence is challenging.

Comparison of robotic-assisted laparoscopic hysterectomy to total laparoscopic hysterectomy in terms of operational complications at a regional institution: A retrospective study.

Objective: With the increased use of total laparoscopic hysterectomy (TLH), the use of robotic-assisted laparoscopic hysterectomy (RALH) has increased due to its technical advantages. On the other hand, RALH has some disadvantages, including its high cost, which includes not only the purchase price of robotic technology systems but also the running cost and long preparation time for setting assistant robots. Therefore, an overall understanding of the characteristics of RALH is needed. Study design: We reviewed the medical records of 432 patients with TLH and 93 patients with RALH from January 1, 2015, to December 31, 2022. In this analysis, we excluded certain cases with concomitant laparoscopic cystectomy (LC) and a heavy uterus (> 400 g). First, the patient characteristics of the TLH and RALH groups, including operation time and blood loss amount, were compared. Then, among these cases, we sought to predict difficult cases for TLH and RALH by identifying risk factors related to each of the following three categories of operational complications: "long operation time", "massive blood loss" and "other complications". For this purpose, multivariate logistic regression analyses were performed to assess the influence of each of 7 representative factors, namely, "advanced age", "high body mass index (BMI)", "nulliparity", "concomitant pelvic lymphadenectomy (PLA)", "heavy uterus", "abdominal adhesion", and "large leiomyoma". Results: In the simple comparison without various factors, there was an advantage of RALH in both the average operation time and blood loss amount. However, in the multivariate logistic regression analyses, a significant risk was detected in the following relationships: 1) between "long-term operation" and "abdominal adhesion" and 2) between "other complications" and "heavy uterus". Conclusions: RALH has sufficient advantages over TLH regarding at least in terms of blood loss amount; however, since RALH may have potential weaknesses in the context of complex cases, additional cases and analyses are needed.

Preventive effect of metronidazole vaginal tablets on vaginal bacteria-related postoperative complications with total laparoscopic hysterectomy.

BACKGROUND: The use of total laparoscopic hysterectomy is increasing. However, as with conventional abdominal hysterectomy, vaginal bacteria-related postoperative complications need to be managed in total laparoscopic hysterectomy. Therefore, we started to combine metronidazole vaginal tablets with intravenous administration of cephem antibiotics immediately before starting surgery to reduce complications. To evaluate the effect of this combination, and to determine the risk factors for these complications, we retrospectively collected medical records from our hospital and performed a multivariate analysis. METHODS: We reviewed the medical records of 520 patients who underwent total laparoscopic hysterectomy from 1 January 2015 to 31 December 2021. Among these cases, we identified 16 cases as having vaginal bacteria-related postoperative complications, defined as needing more than one additional day for treatment of postoperative complications, namely postoperative infection (10 cases) and vaginal dehiscence (6 cases). First, we evaluate the effect of metronidazole vaginal tablets by dividing the patients into two groups according to whether metronidazole vaginal tablets were used, and comparing the vaginal bacteria-related postoperative complication rates and other indices. Second, we performed a multivariate logistic regression analysis to assess the influence of each of 17 representative factors, including patient characteristics and symptoms, uterus and leiomyoma sizes, concomitant procedures such as laparoscopic cystectomy and pelvic lymphadenectomy, and others. RESULTS: In the multivariate analysis of the 520 cases, we confirmed that the use of metronidazole vaginal tablets could reduce the vaginal bacteria-related postoperative complications rate by more than half (odds ratio, 0.36). In addition to metronidazole vaginal tablets use, concomitant laparoscopic cystectomy and blood transfusion were associated with significant increases in the vaginal bacteria-related postoperative complication rate. CONCLUSIONS: The effect of the addition of metronidazole vaginal tablets to pre- and postsurgical treatment on the reduction of vaginal bacteria-related postoperative complications was confirmed. This easy, safe, and low-cost method may improve the management of total laparoscopic hysterectomy.

The effect of temporary uterine artery ligation on laparoscopic myomectomy to reduce intraoperative blood loss: A retrospective case-control study.

Objective: To reduce intraoperative blood loss in laparoscopic myomectomy, uterine artery occlusion or temporary uterine artery clipping have been employed. Recently, in addition to these techniques, temporary uterine artery ligation has been reported as a new method that has less invasive effects on fertility and needs no special devices to be used. This study aimed to evaluate the effect of temporary uterine artery ligation to minimize intraoperative blood loss during laparoscopic myomectomy. Study Design: This was a retrospective case-control study at the department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine. A total of 264 patients with uterine leiomyoma who underwent laparoscopic myomectomy were enrolled in this study. We divided the patients into two groups, those who underwent temporary uterine artery ligation (52 patients) and those who did not (212 patients) and compared the operation time, blood loss volume, and other indexes. Second, to identify influential factors, we assessed the effects of 11 representative factors on massive blood loss or a prolonged operation time using multivariate analysis. Results: The intraoperative blood loss volume was decreased by approximately half with the addition of temporary uterine artery ligation (75.1 ± 73.6 ml vs. 158.5 ± 233.2 ml, p = 0.011), but the operation time was longer (200.5 ± 46.9 min vs. 160.1 ± 51.3 min, p < 0.001). Among the 264 patients, 25 patients (9/52 in the case group and 16/212 in the control group) had a prolonged operation time (≥ 240 min), and 24 patients (1/52 in the case group and 23/212 in the control group) experienced massive blood loss (≥ 400 ml). In the multivariate analysis, high body mass index, concomitant surgery and temporary uterine artery ligation showed a positive association with a prolonged operative time, and the presence of single leiomyoma showed a negative association. Concomitant surgery and the presence of large leiomyoma showed a positive association with massive blood loss, and temporary uterine artery ligation showed a negative association. Conclusions: By performing temporary uterine artery ligation during laparoscopic myomectomy, the volume of intraoperative blood loss could be decreased, especially in patients with large leiomyomas. However, because this procedure prolongs the operation time, there is still room for improvement.

Unilateral uterine artery embolization and Bakri tamponade balloon insertion in the treatment of acute puerperal uterine inversion: a case report.

BACKGROUND: Acute puerperal uterine inversion is rare but may cause massive postpartum blood loss due to uterine atony. Therefore, these patients must be diagnosed, and uterine replacement must be performed as soon as possible. However, in some cases, active bleeding due to uterine atony becomes uncontrollable, even though the uterine inversion itself is treated. In these cases, additional treatments, including surgical procedures, are needed. CASE PRESENTATION: A 41-year-old Japanese woman, gravida 1, para 0, was hospitalized for labor induction at 40 weeks and 3 days of gestational age. She had a vacuum-assisted delivery after 3 days of oxytocin administration, but acute uterine inversion occurred. Although replacement of the inverted uterus was successful by manual repositioning and Bakri balloon tamponade insertion, massive postpartum hemorrhage caused by uterine atony became uncontrollable. In this situation, since disseminated intravascular coagulation had developed, we used uterine artery embolization to stop the bleeding. After detecting the pseudo-aneurysmal sac and tortuous vessels of the right uterine artery, transcatheter right-sided uterine artery embolization was performed. Thirteen days after uterine artery embolization, she was discharged with no complications. CONCLUSIONS: In cases of disseminated intravascular coagulation caused by massive postpartum bleeding, uterine artery embolization may often be selected. In our case, since we performed angiography to detect the main bleeding site, the hemorrhage could be stopped with unilateral uterine artery embolization alone, without hysterectomy.

Successful Management of a Noncommunicating Rudimentary Uterine Horn Pregnancy by Laparoscopic Surgery: A Case Report and Literature Review.

Pregnancy in a noncommunicating rudimentary horn is extremely rare but can cause serious clinical complications, such as uterine rupture. The standard treatment is excision of the rudimentary horn, and recently, in some cases, laparoscopic resection has been performed in the first trimester of gestation. Herein, we present a case of noncommunicating rudimentary horn pregnancy (NCRHP), which was diagnosed by magnetic resonance imaging at 6 weeks of gestation and treated by laparoscopic surgery. However, we have also found some rare cases in which patients could obtain live newborn babies. Since management is affected by the different levels of obstetric medical care and diagnostic tools, we also performed a review and analysis of NCRHP. A PubMed search yielded 103 cases reported in the English literature. Correct diagnosis and laparoscopic treatment were achieved more frequently in developed countries, especially in the first trimester of gestation. On the other hand, symptoms, including abdominal pain and hypovolemic shock, tended to occur in the second trimester of gestation. This period was also found to be a risk factor for uterine rupture. Among 18 patients at the third trimester of gestation, 13 obtained live neonatal infants. Therefore, detailed information about this disease is crucial for proper treatments.

Influence of a patient education and care program on women undergoing non-assisted reproductive technology fertility treatment.

PURPOSE: To determine the influence of a patient education and care program on the quality of life (QOL) of female patients undergoing non-assisted reproductive technology (ART) fertility treatment. METHODS: Participants completed the MOS 36-Item Short-Form Health Survey and fertility QOL (FertiQoL) questionnaires at baseline and at 3, 6, and 12 months of treatment. The responses of patients who underwent three sessions of the program (at baseline, 3 months, and 6 months of treatment) were compared with those of patients who did not receive the program. RESULTS: This study compared 69 patients who received an additional care program with 104 patients in the control group, all from 13 facilities. Treatment FertiQoL responses (p = 0.004) and treatment tolerability (p = 0.043) differed between the program and control groups at 3 months using the repeated measures mixed model. The cost of treatment per pregnancy was lower in the program group than in the control group. CONCLUSION: The patient education and care program provided by reproductive fertility specialists or fertility nurses during non-ART fertility programs improves patient satisfaction.

Predictive factors of spontaneously regressed uterine endometrial polyps during the waiting period before hysteroscopic polypectomy.

BACKGROUND: The presence of uterine endometrial polyps is associated with not only abnormal uterine bleeding but also infertility, so the use of hysteroscopic polypectomy has been increasing. This operation is considered to increase cost-effectiveness when performed prior to infertility treatments. However, there are typical problems to consider, including the possibility of spontaneous regression of the polyp and the duration of complete endometrial wound healing after surgery. Meaningless interventions must be avoided, when possible. Therefore, data acquisition and analysis of various findings obtained from surgery have become important for improving treatment procedures and patient selection. To estimate the spontaneous regression rates and contributions of multiple factors to uterine endometrial polyps during the waiting period (approximately 2-3 months) before hysteroscopic polypectomy, we performed a multivariate analysis of data from the records in our hospital. METHODS: The medical records of 450 cases from September 2014 to April 2021 in our hospital were retrospectively reviewed under the approval of our Institutional Review Board. We included all cases of hysteroscopic polypectomy with postoperative pathological diagnosis. We defined cases as having a "spontaneously regressed polyp" when the target polyp was not detected by postoperative pathological examination. We extracted data on the following ten factors: "Advanced age" (≥ 42 years), "Small polyp" (< 10 mm), "High body mass index" (≥ 25 kg/m2), "Nulliparity," "Single polyp," "Infertility," "Hypermenorrhea," "Abnormal bleeding," "No symptom," and "Hormonal drug use." We also classified cases into five groups according to the size of the polyp (≤ 4.9 mm, 5.0-9.9 mm, 10.0-14.9 mm, 15.0-19.9 mm, and ≥ 20.0 mm) and determined the frequency of spontaneously regressed polyp in each group. RESULTS: After exclusion of cases with insufficient data or other diseases, such as submucosal leiomyoma, 424 cases were analyzed. Among them, 28 spontaneously regressed polyps were identified, and the highest frequency of spontaneously regressed polyp was detected among the cases with polyps measuring 5.0-9.9 mm (16.4%). On multivariate analysis of the ten factors, "Small polyp" and "Hormonal drug use" were found to significantly impact the frequency of spontaneously regressed polyp. CONCLUSIONS: On the basis of the factors identified in this analysis, the indications for observation or medical therapy adapted to small polyps might be expanded.

A retrospective study of 323 total laparoscopic hysterectomy cases for various indications and a case report treating caesarean scar pregnancy.

BACKGROUND: The application of laparoscopic surgeries has been increasing, and various uterine diseases in addition to leiomyoma/adenomyoma have become indications for total laparoscopic hysterectomy (TLH). Therefore, data acquisition and analysis of TLH procedures, including TLH for rare uterine diseases, have become important for improving surgical procedures and patient selection. To determine the prevalence of and risk factors for the occurrence of intraoperative and postoperative complications of TLH, we performed a multivariate analysis of the records in our hospital. METHODS: We retrospectively reviewed the medical records of 323 patients who underwent TLH for the treatment of leiomyoma/adenomyoma (278 cases), low-grade (pre)malignant uterine tumours (40 cases) and other rare uterine diseases (5 cases) from January 1, 2015, to December 31, 2019. Of the rare uterine diseases, one case of caesarean scar pregnancy for which TLH was performed is introduced as a case report. To assess the effects of 11 representative factors, including patient characteristics, uterus and leiomyoma sizes, indications for TLH and others, we performed a multivariate logistic regression analysis. RESULTS: Among the 323 cases, 20 intraoperative complications and 15 postoperative complications were reported. In the multivariate analysis, "ovarian tumour" and "heavy uterus" were positively associated and "nulliparity" was negatively associated with intraoperative complications. There were no significant risk factors for postoperative complications. The only risk factor for operative complications directly related to the resected uterus was "heavy uterus". Therefore, we could perform TLH relatively safely for patients with other indications besides leiomyoma/adenomyoma. CONCLUSIONS: Considering the factors detected in this analysis, the indications for TLH may be expanded. Owing to the increase in TLH for indications other than leiomyoma/adenomyoma, a more accurate determination of the treatment approach can be achieved.

Significant risk factors for malignant transformation of ovarian endometrioma during dienogest treatment: a case report and retrospective study.

BACKGROUND: To determine the prevalence of and risk factors for malignant transformation of ovarian endometrioma during dienogest therapy, which is very rare, we examined multiple cases of malignant transformation of ovarian endometrioma during dienogest therapy and performed a multivariate analysis of the records in our hospital. METHODS: The medical records of 174 patients who underwent DNGT for the treatment of OMA from June 1, 2011, to May 31, 2018, were reviewed retrospectively with the approval of the Human Ethical Committee of the University of Teikyo Hospital. And we provided one representative case of MT with obtaining written informed consent. To assess the effects of six representative factors, including advanced age, parity, surgical history, and endometrial cyst characteristics (including 3 factors), on the possibility of malignant transformation, we performed a multivariate logistic regression analysis. RESULTS: Of the 174 cases, 4 were diagnosed with malignant transformation, and these cases are reported. In the multivariate analysis, advanced age (P = 0.0064), nullipara (P = 0.0322), and enlargement (P = 0.0079) showed significant differences for malignant transformation occurrence. All 4 malignant transformation cases were among the 19 patients who had all of these 3 factors. CONCLUSIONS: For a more accurate determination of the treatment approach, a larger sample size will be needed to determine the risk factors for malignant transformation during dienogest therapy.

Altered lower limb kinematics and muscle activities in soccer players with chronic ankle instability.

OBJECTIVE: To examine the lower limb kinematics and muscle activities in diagonal single-leg rebound jump in soccer players with chronic ankle instability (CAI). DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: Thirty male collegiate soccer players participated: 15 with CAI were compared with 15 without CAI, matched by physical description. INTERVENTION(S): In the diagonal single-leg rebound jump, participants stood on one leg on a 30-cm high box, hopped down diagonally (45°) onto a force plate, and jumped vertically as high as possible with hands on their hips. MAIN OUTCOME MEASURES: Hip, knee, and ankle kinematics were acquired using a motion capture system. The activity of the gluteus medius, hip adductor, and lower leg muscles was recorded using electromyography. Jump performance was calculated using a force plate. RESULTS: The CAI group had (i) decreased hip adduction, knee flexion, external rotation, and dorsiflexion angle; (ii) reduced hip adductor and peroneus muscle activations; and (iii) reduced jump height and short flight time. CONCLUSIONS: Male collegiate soccer players with CAI showed altered kinematics and muscle activities during a diagonal single-leg rebound jump; this may adversely affect rebound jump performance.

Endophytic-Type Endometrial Cancer with Adenomyosis Successfully Diagnosed with Hysteroscopic Endometrial Biopsy Using an 8.3-mm Operative Resectoscope: A Case Report.

In order to diagnose endometrial cancer preoperatively, outpatient endometrial biopsy with a curette is frequently performed owing to its convenience. However, in some cases, gynecologists fail to diagnose endometrial cancer via outpatient endometrial biopsy because of the cancer's distribution in the uterus and its consistency. A 57-year-old Japanese woman (gravida 4 para 4) presented with a 6-month history of light but intermittent postmenopausal vaginal bleeding. A malignant uterine tumor was strongly suspected after imaging using ultrasound examination and magnetic resonance imaging; however, a precise pathological diagnosis was not achieved despite multiple outpatient endometrial biopsies with the aid of office hysteroscopy. Based on an endometrial biopsy obtained using a cutting loop electrode on an 8.3-mm operative resectoscope, we reached a diagnosis of endophytic-type endometrial cancer, which is in accordance with the final pathological diagnosis after abdominal hysterectomy. Three months after her first visit to our hospital, total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic/para-aortic lymph node dissection were performed. Macroscopically, the endometrium was atrophic, and there was no obvious mass in the uterine cavity; however, microscopically, the cancer cells mainly existed in the deep myometrium and the final diagnosis was International Federation of Gynecology and Obstetrics (FIGO) stage IB endometrial cancer. Operative biopsy of the uterine endometrium and deep myometrium using hysteroscopy confirmed an accurate preoperative diagnosis of uterine endometrial cancer specifically of the endophytic type.

Suturing method as a factor for uterine vascularity after laparoscopic myomectomy.

OBJECTIVE: To evaluate the vascularity of the myometrium after laparoscopic myomectomy sutured by two different methods using contrast-enhanced Magnetic Resonance Imaging. STUDY DESIGN: Twenty-eight women who had symptomatic leiomyomas and underwent laparoscopic myomectomy between June 2013 and July 2014 were included in the present study. In the first half period, continuous sutures were used in 12 patients, and in the latter half period, single interrupted sutures were used in 16 patients. Contrast-enhanced Magnetic Resonance Imaging was used 3 or 6 months after surgery to evaluate vascularity after laparoscopic myomectomy. We defined avascularity index as the percentage of avascular area after surgery to cross sectional area of myoma before surgery. The Wilcoxon rank-sum test was applied to compare avascularity indeces in the two study groups. RESULTS: At 3 months after surgery, avascularity index in continuous sutures group was significantly higher than that in single interrupted sutures group (median 5.0 vs.1.2, p<0.001), suggesting a poorer vascular recovery of the myometrium sutured continuously. CONCLUSION: Simple interrupted suturing might be superior to continuous suturing in terms of vascularity evaluated using contrast enhanced Magnetic Resonance Imaging.

Elective single-embryo transfer improves cumulative pregnancy outcome in young patients but not in women of advanced reproductive age.

PURPOSE: The purpose of the present study is to assess the significance of elective single-embryo transfer (eSET) in older women. METHODS: The outcomes of assisted reproductive technology between 2001 and 2013 at single institution were retrospectively evaluated. Cumulative live birth rates (CLBRs) in one oocyte retrieval cycle were compared between those who underwent eSET and multiple embryo transfer (MET) in fresh cycles. RESULTS: The outcomes of 429 eSET cycles and 965 MET cycles were compared. CLBRs in eSET were higher than those of MET in women under 37 and were comparable in women aged 37 and over. The analysis of the outcomes separately in three age subgroups showed a significantly higher CLBR in young eSET (aged under 37) than that in young MET and similar CLBR between older (aged 37-40 and over 40) eSET and MET. Multiple birth rates were lower in eSET in all age groups. Multivariate logistic regression analyses showed that, in women aged under 37, number of frozen embryos, presence of good-quality embryos, and eSET were significantly related to cumulative live birth. In women aged between 37 and 40, age and number of frozen embryos were significantly related, while eSET was not. CONCLUSIONS: eSET in women under 37 resulted in increased CLBR compared with MET. In women aged between 37 and 40, CLBR in eSET group was similar with that in MET group. In both age groups, eSET reduced multiple birth rates. The significance of eSET in older women is limited presently, and further research on the strategy to improve cumulative outcomes is necessary.

Identifying patients who can improve fertility with myomectomy.

OBJECTIVE: To identify the characteristics of cases and fibroids that will indicate which patients should undergo myomectomy to improve fertility. MATERIALS AND METHODS: We recruited patients (n=101) who had undergone myomectomy to improve fertility and received follow-up care for at least six months by the hospital. Medical records were retrospectively reviewed to analyze the pregnancy rates after myomectomy and to identify clinical factors that correlate with pregnancy rates. Cumulative pregnancy rates were analyzed using the Kaplan-Meier method and the Log rank test. The patients were then divided into three groups according to the timing of the myomectomy. The analysis was performed for all patients, for patients in the post-superovulation and/or intrauterine insemination (post-SO/IUI) group and the post-assisted reproductive technology (post-ART) group combined, and for patients in the post-ART group. RESULTS: Sixty-three pregnancies were achieved by 58 patients (57.4%) who underwent myomectomy. The mean time period between surgery and conception was 9.8 months. Most pregnancies (91.5%) were achieved within two years after surgery. Pregnancy rates were higher in patients aged less than 36 years, with no male factors, and without severe endometriosis, in comparison with patients 36 years of age or older (p<0.05), with male factor (p<0.05), and severe endometriosis (p<0.05). In the analysis of the post-ART group, pregnancy rates were higher (p<0.05) in cases where enucleation had penetrated the endometrial cavity in comparison with patients where the cavity was not penetrated; however, fibroid characteristics did not correlate with the post-myomectomy pregnancy rate in the post-SO/IUI plus post-ART group. CONCLUSION: Post-myomectomy pregnancy rates were higher in women who did not have additional infertility factors. These results suggest that the removal of fibroids benefits especially patients who suffer from infertility of an otherwise unknown cause: surgery should be strongly recommended for these patients. Our study also shows the difficulty in identifying fibroids for removal to improve fertility. Further studies are needed to develop new diagnostic techniques for identifying patients who can improve fertility with myomectomy.

The outcome of infertility treatment in patients undergoing assisted reproductive technology after conservative therapy for endometrial cancer.

PURPOSE: To elucidate the problems in infertility treatment for women after conservative therapy for endometrial cancer (EC) or atypical complex endometrial hyperplasia (ACEH). METHODS: The clinical outcomes of 21 patients who underwent assisted reproductive technology after conservative therapy (group A) and 42 control women (group B) were retrospectively analyzed. RESULTS: There was no significant difference in the number of retrieved oocytes, fertilization rate or the number of transferred embryos between the two groups. Women in group A had a significantly thinner endometrium and a reduced implantation rate compared to those for women in group B. There was no significant difference in the cumulative clinical pregnancy and delivery rates between group A and B. The patients in group A required significantly more embryos for achieving a live-birth. CONCLUSIONS: Our results indicate that a thin endometrium after repeated curettage may have a negative effect on endometrial receptivity of patients after conservative treatment for EC/ACEH. Clinicians should reconsider their present protocols and make efforts to minimize the damage to normal endometrium.

Concomitant ovarian drilling and oocyte retrieval by laparoendoscopic single-site surgery led to live birth using in vitro maturation of oocyte and transfer of frozen-thawed blastocyst in woman with polycystic ovary syndrome.

This case report describes a case of concomitant ovarian drilling and retrieval of oocytes using laparoendoscopic single-site surgery and the resultant birth of a healthy infant after transfer of frozen-thawed blastocyst from in vitro matured oocyte in a woman with polycystic ovary syndrome. A 33-year-old woman presented with anovulatory, clomiphene-resistant polycystic ovary syndrome, and 1-year history of infertility. Thirty-seven immature oocytes were retrieved and multiperforation of ovaries was performed at the same time by laparoendoscopic single-site surgery. Twenty-three oocytes reached metaphase II after 24-h culture in in vitro maturation medium, which was followed by intracytoplasmic sperm injection. Eventually, seven embryos were vitrified and spontaneous ovulation was restored after the operation. Although the first single frozen-thawed blastocyst transferred in a natural cycle ended up a biochemical pregnancy, the second frozen-thawed blastocyst transfer resulted in successful pregnancy, followed by live birth of a healthy male infant.

Factors that predict poor clinical course among patients hospitalized with pelvic inflammatory disease.

AIM: The aim of this study was to identify factors that can predict clinical course among patients hospitalized with pelvic inflammatory disease (PID). METHODS: Ninety-three patients who needed hospitalization with a diagnosis of PID were retrospectively studied. Patients who were discharged within 7 days by conservative treatment were defined as favorable course cases (n = 44). Patients who needed more than 7 days of hospitalization and/or surgery were defined as poor course cases (n = 49). Twenty variables were evaluated by univariate and logistic regression analysis: age, history of pregnancy/delivery, gynecological open/laparoscopic surgery, PID, oral contraceptives/intrauterine device use and intrauterine operation before onset, body temperature, signs of peritoneal irritation, vomiting/diarrhea, abnormal vaginal discharge, endometriosis/fibroid/adenomyosis/any cystic lesion detected by ultrasonography, white blood cell counts/C-reactive protein (CRP) levels . The cut-off value was calculated by receiver-operator curve (ROC) analysis. RESULTS: Factors associated with poor clinical course were advanced age (P < 0.01), history of gynecological open surgery (P < 0.05), any cystic lesion detected by ultrasonography (P < 0.05) and high CRP levels (P < 0.05). High CRP levels and intrauterine operation before onset were independently associated with poor clinical course. The cut-off value for CRP was 4.4 mg/dL. CONCLUSION: This study identified variables that can predict poor clinical course of PID. These results can assist gynecologists with identifying patients at risk and optimizing the choice of management.