Effect of length of controlled ovarian hyperstimulation using a gonadotropin-releasing hormone antagonist on in vitro fertilization pregnancy rates.

OBJECTIVE: To compare pregnancy outcomes between shorter and longer in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles using GnRH antagonist protocol. STUDY DESIGN: Retrospective cohort analysis at a large military academic hospital. A total of 351 patients underwent 412 IVF/ICSI cycles using a GnRH antagonist protocol from September 2002 through May 2008. Clinical pregnancy and live birth rates for all IVF/ICSI cycles were compared independently for both total length of ovarian stimulation with gonadotropins (< 10 days vs. > or = 10 days) and GnRH antagonist use (< 4 days vs. > or = 4 days), respectively. RESULTS: Clinical pregnancy rates were 54.6% among cycles with total gonadotropin use <10 days vs. 48.6% for those cycles > or = 10 days, odds ratio 0.82 (0.53-1.27); live birth rates were 50.0% vs. 47.7%, odds ratio 0.91 (0.59-1.42). Clinical pregnancy rates were 54.0% among cycles with GnRH antagonist use < 4 days vs. 52.8% with GnRH antagonist use > or = 4 days, odds ratio 0.95 (0.62-1.45); live birth rates were 46.8% vs. 50.4%, odds ratio 1.15 (0.76-1.76). CONCLUSION: Clinical pregnancy and live birth rates are not adversely affected by longer IVF/ICSI cycles using GnRH antagonists.

Complications of primary closure of classic bladder exstrophy.

PURPOSE: We report the urological, orthopedic and neurological complications of primary closure of classic bladder exstrophy using modern staged repair of exstrophy. MATERIALS AND METHODS: An approved database identified 137 males and 57 females with classic bladder exstrophy who underwent primary repair by 1 of 2 surgeons in 23 years. A total of 185 patients underwent primary closure using modern staged repair of exstrophy with or without osteotomies, whereas 9 underwent delayed primary closure with epispadias repair at age 12 months. Of the patients 63 received osteotomies. Mean age at closure was 60 days and mean followup was 9 years. RESULTS: There were 14 major complications (11%) and 27 minor complications (14%). Major urological complications included bladder prolapse or dehiscence in 6 male patients (3%), which was successfully reclosed. Major orthopedic complications, including osteotomy nonunion in 2 cases, leg length inequality in 1 and persistent joint pain in 1, developed in 4 of the 63 patients (6%) who underwent osteotomy. Major neurological complications included femoral nerve palsy in 4 patients (2%). There were 21 minor urological complications (11%), including posterior bladder outlet obstruction in 4 cases, urethrocutaneous fistula in 2, suprapubic tube removal in 2, intrapubic stitch erosion in 4, febrile urinary tract infection in 6 and surgical site infection in 3. Six patients (3%) had minor orthopedic complications, including pelvic osteomyelitis in 1, pin site infection in 3 and a pressure sore from immobilization in 1. CONCLUSIONS: Closure of bladder exstrophy is a safe surgery with an acceptable risk of complications. A critical review of outcomes provides insight to further refine the technique and manage complications when they develop.

Variations in L-selectin ligand expression in the luteal-phase endometrium after final oocyte maturation with human chorionic gonadotropin compared with a gonadotropin-releasing hormone agonist.

Final oocyte maturation was achieved by using hCG or two doses of leuprolide acetate in 16 oocyte donors after a GnRH antagonist protocol. Administration of hCG was associated with a statistical trend toward increased L-selectin ligand expression in the endometrium on postretrieval day 5, compared with the leuprolide acetate group.

Elevated HCG outside of pregnancy--diagnostic considerations and laboratory evaluation.

UNLABELLED: Human chorionic gonadotropin (hCG) is a glycoprotein hormone produced by trophoblastic tissues, and its identification is frequently relied upon to establish the diagnosis of pregnancy. Entities other than pregnancy, such as false-positive hCG results, pituitary hCG, exogenous hCG, and both trophoblastic and nontrophoblastic neoplasias, can also cause laboratory assays for hCG to show positive results. Because of their rarity, these conditions are not commonly recognized, and the steps to differentiate between them are not widely known. Discriminating between the causes of elevated hCG in nonpregnant patients can be confusing. An understanding of the differential diagnosis and awareness of available diagnostic modalities are essential for accurate diagnosis and avoidance of potentially harmful treatments. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to state the importance of types of human chorionic gonadotropin (hCG), recall their presence in both trophoblastic and nontrophoblastic neoplasias, and explain how important it is to distinguish between the various causes of an elevated serum hCG to avoid harmful treatments.

Laparoscopic tubal reanastomosis using robotics: experience from a teaching institution.

PURPOSE: Tubal reanastomosis typically requires a laparotomy and in the past few years has been performed much less frequently due to the development and success of in vitro fertilization. Laparoscopic tubal anastomosis eliminates the need for laparotomy and can be performed in an out-patient setting. MATERIALS AND METHODS: From October 2003 to September 2004, five patients who had previous tubal sterilization and requested tubal reanastomosis underwent laparoscopic tubal reanastomosis with the use of the da Vinci surgical system (Intuitive Surgical, Mountain View, CA). RESULTS: Ten fallopian tubes were successfully reconstructed, as confirmed by chromopertubation at the end of the procedure. Patency was confirmed by hysterosalpingogram in seven out of eight tubes. The mean (+/- standard deviation) time of the procedure was 172 +/- 53 min. The mean time for docking the robotic arms to the patient was 62 +/- 16.8 min and the mean robotic time was 97 +/- 36 min. There were two live births, one ectopic pregnancy, and one biochemical pregnancy. The mean time to conception was 5.5 +/- 2 months. CONCLUSION: Laparoscopic microsurgical tubal reanastomosis after tubal sterilization can be performed using a remote-controlled robotic system. Systematization of the operative steps allowed for operative times that compare favorably with the time needed for open microsurgical techniques. Larger series are needed to standardize the procedure and confirm postoperative fecundity rates.

Repeat pelvic osteotomy in cloacal exstrophy: applications and outcomes.

PURPOSE: Pelvic osteotomies have been shown to enhance success rates for classic exstrophy patients when closed primarily or secondarily after initial failure. Primary closure of cloacal exstrophy also benefits from osteotomy but this has yet to be shown for re-closure of cloacal exstrophy failures. This study looks at the applications, complications, and long-term success rates in this very select group of patients. METHODS: We extracted from an institutionally approved exstrophy database 15 patients who had undergone repeat pelvic osteotomy and analyzed patient history, complications and orthopedic outcomes. RESULTS: All patients who underwent reclosure at our institution remain closed. Major complications were seen in two patients and minor complications in four patients. Urinary continence was achieved in 10 patients with augmentation and continent stoma formation, urinary diversion was performed in two patients and three patients await a continence procedure. CONCLUSIONS: Repeat pelvic osteotomy in cloacal exstrophy is successful and the complication rate is low. Pelvic osteotomy is associated with enhanced success rates of primary and secondary closure with better cosmesis of the abdominal wall and genitalia. Intrasymphyseal plates along with gradual reduction of the extreme diastasis utitlizing an external fixation device can be beneficial prior to further genitourinary surgery.

Immunological localization of syndecan-1 in human endometrium throughout the menstrual cycle.

OBJECTIVE: To examine the expression of syndecan-1 in the endometrium during the menstrual cycle. DESIGN: The expression of syndecan-1 was determined by tissue microarray and immunohistochemistry. SETTING: Academic clinical and research laboratories. PATIENT(S): Seventy-one regularly cycling women who underwent endometrial biopsy. INTERVENTION(S): Endometrial samples representing five stages of the menstrual cycle were used for the study. MAIN OUTCOME MEASURE(S): Semiquantitative analysis by evaluating the intensity of immunohistochemical reactivity of syndecan-1 by using a modified HSCORE. RESULT(S): Endometrial syndecan-1 was expressed in the luminal and glandular epithelium as well as in the stroma throughout the menstrual cycle in a nonsynchronized fashion. In the luminal epithelium, the expression of syndecan-1 was statistically significantly higher in the mid-secretory phase when compared with the proliferative phase. In the stroma, however, the expression of syndecan-1 was down-regulated after ovulation and remained at a low level through the secretory phases. Differences between the proliferative and mid secretory, as well as between the ovulatory and the early, mid, and late secretory phases, all were statistically significant. CONCLUSION(S): Syndecan-1 is up-regulated in luminal epithelial cells during the mid-secretory phase and is down-regulated in the stroma during the early to late secretory phases. The differential expression of syndecan-1 coincides with the endometrial remodeling throughout the menstrual cycle.

Effect of luteal-phase support on endometrial L-selectin ligand expression after recombinant follicle-stimulating hormone and ganirelix acetate for in vitro fertilization.

CONTEXT: The impact of different types of luteal phase support on endometrial receptivity after ovarian stimulation has not been investigated. OBJECTIVE: Our objective was to evaluate the impact of different luteal-phase support protocols on sex steroid levels and on endometrial expression of L-selectin ligand after ovarian hyperstimulation with a GnRH antagonist protocol. PATIENTS AND DESIGN: Seventeen oocyte donors who underwent ovarian stimulation with a recombinant FSH/ganirelix acetate protocol were randomized into three groups: group I had no luteal-phase support; group II had luteal support with micronized progesterone; and group III had luteal support with progesterone plus 17beta-estradiol. All donors had endometrial biopsies on the day of retrieval, and then 3, 5, and 10 d after retrieval. In addition, they had serum estradiol and progesterone measurements on d 3, 5, and 10. MAIN OUTCOME MEASURES: Endometrial L-selectin ligand expression was detected by immunohistochemical staining in the luminal and glandular epithelium. A histological score was used for the quantification of the immunostaining. Sex steroid levels were measured during the luteal phase. RESULTS: By d 10 after retrieval, there was a significant decrease in mean progesterone levels in group I compared with the other two groups that may reflect the expected demise of the corpus luteum. There was also a significant increase in the presence of L-selectin ligands in the luminal epithelium in group III. CONCLUSIONS: During controlled ovarian stimulation with a GnRH antagonist protocol, luteal-phase support with micronized progesterone and 17beta-estradiol seem to increase endometrial L-selectin ligand expression in the luminal endothelium.

Septate uterus with cervical duplication and a longitudinal vaginal septum: a müllerian anomaly without a classification.

OBJECTIVE: To report a rare uterine anomaly of a septate uterus, double cervix, and double vagina. DESIGN: Case report. SETTING: A university-based reproductive endocrinology center. PATIENT(S): A 20-year-old nulligravida with primary infertility. INTERVENTION(S): Clinical examination and surgical resection of a vaginal septum with hysteroscopic examination of both hemicavities. MAIN OUTCOME MEASURE(S): Description and treatment for a rare uterine anomaly and a subsequent literature search. RESULT(S): Successful resection of vaginal septum and subsequent spontaneous pregnancy. CONCLUSION(S): This rare anomaly is not explained by classic embryologic teaching and is not described by the classification system currently used to describe müllerian anomalies.

Long-term corticosteroid replacement and bone mineral density in adult women with classical congenital adrenal hyperplasia.

CONTEXT: Concern has been raised regarding the potential impact of chronic glucocorticoid therapy on the bone mineral density (BMD) of patients with congenital adrenal hyperplasia (CAH). OBJECTIVE: The purpose of this investigation was to assess the impact of chronic glucocorticoid replacement in adult women with classical CAH. PATIENTS AND DESIGN: We used dual energy x-ray absorptiometry to evaluate lumbar spine and whole body BMD in 11 women with salt-losing (SL) CAH and 15 with the simple virilizing form. Physical characteristics and serum hormone concentrations were also measured. Results were compared with those of unaffected sisters of CAH patients (n = 9). MAIN OUTCOME MEASURE: BMD was the main outcome measure. RESULTS: Osteopenia was noted in 45% of SL CAH patients, 13% of patients with the simple virilizing form, and 11% of controls. Lumbar spine and whole body BMDs of CAH subjects were lower than those of controls (P < 0.05). Compared with CAH subjects with normal BMD, those with osteopenia had reduced serum levels of dehydroepiandrosterone sulfate and dehydroepiandrosterone. Adrenal androgen levels were particularly suppressed among postmenopausal women receiving glucocorticoid replacement. CONCLUSIONS: Adult women with classical CAH treated with long-term glucocorticoids are at risk for decreased BMD, especially those with the SL form. Oversuppression of adrenal androgens is associated with increased risk for bone loss in this population.

Maternal and fetal tuberous sclerosis complicating pregnancy: a case report and overview of the literature.

Tuberous sclerosis complex (TSC) is an autosomal-dominant phakomatosis that can result in cardiac and central nervous system lesions and may adversely impact fetal and maternal health. We report a case of a 19-year-old primagravida with TSC whose pregnancy was complicated by preeclampsia, preterm labor, and fetal demise. The fetus, also affected with TSC, was diagnosed with a cardiac rhabdomyoma on ultrasound at 24 gestational weeks and intracranial tubers on fetal magnetic resonance imaging at 26 gestational weeks. Hydrops fetalis developed in the 30th gestational week. Fetal demise occurred during induction of labor. A systematic review of the medical literature was conducted. Our objective was to quantify maternal and fetal morbidity and mortality associated with TSC. We identified 36 additional cases of fetal TSC with cardiac rhabdomyoma diagnosed prenatally. Including our case, we also identified 23 pregnancies (17 mothers) complicated by maternal TSC. Rates of complications are calculated. We conclude that pregnancies complicated by maternal or fetal TSC deserve careful vigilance. Although benign histologically, cardiac rhabdomyomas can result in fetal morbidity and mortality.

Pseudomonas aeruginosa-infected IUD associated with pelvic inflammatory disease. A case report.

BACKGROUND: While pelvic infection is known to be an infrequent complication of intrauterine device (IUD) use, infections are usually related to microorganisms introduced at the time of insertion or by sexual contact. CASE: We diagnosed a 35-year-old woman with an IUD for 6 years with pelvic inflammatory disease (PID) and implemented antibiotic therapy. Her clinical course worsened, and exploratory surgery revealed a right tuboovarian abscess with multiple loculated pelvic abscesses. Culture of the IUD found heavy growth of Pseudomonas aeruginosa. CONCLUSION: P aeruginosa has not previously been described in association with infections of the upper female genital tract. Double coverage with appropriate antipseudomonal agents is essential for proper treatment of pseudomonal infections.