Fertility after treatment of a noncommunicating rudimentary horn pregnancy: A case report.

Rudimentary horn pregnancies are rare but are associated with high mortality and morbidity. The diagnosis can be difficult as it may be challenging to distinguish a rudimentary horn pregnancy from an intrauterine pregnancy on ultrasound. Magnetic resonance imaging can often be used to confirm a rudimentary horn pregnancy. When a second-trimester rudimentary horn pregnancy is diagnosed, surgical intervention should be performed to avoid uterine rupture and hemoperitoneum. The correct diagnosis and management of rudimentary horn pregnancies help to preserve the fertility of younger patients. This case report describes a second-trimester rudimentary horn pregnancy that was diagnosed by ultrasound and magnetic resonance imaging. It was then surgically resected via laparotomy. This patient maintained her fertility and was able to conceive naturally, leading to an uncomplicated term pregnancy.

Modeling follicle stimulating hormone levels in serum for controlled ovarian hyperstimulation I: comparing gonadotropin products.

BACKGROUND: Despite the dangers of gonadotropin administration, our understanding of serum levels of gonadotropins in our patients is poor. We created a mathematical model of gonadotropin administration in order to learn about the temporal profiles of Follicle Stimulating Hormone (FSH) levels in patients related to the doses of different gonadotropin products administered. METHODS: Model parameters for each product were determined from published pharmacokinetic information available from the manufacturers. RESULTS: For each product, serum levels of FSH rose then fell following a single injection of FSH. When a gonadotropin dose was injected repeatedly (daily), each injection resulted in a peak level of FSH that was higher than the level attained from the previous injection. Daily FSH peaks rose asymptotically, requiring 3-10 days to approach the maximum. The maximum averaged 3.5 times the peak of the first injection. Decline of FSH following the final injection required 3-10 days to approach the baseline. Time courses and peak values of FSH using different gonadotropin preparations varied widely. CONCLUSION: Knowledge of the slow changes of FSH that occur during modeled FSH administration will provide a framework for understanding the gonadotropin profiles that occur in patients during controlled ovarian hyperstimulation.

Relaxin receptor LGR7 (RXFP1) is regulated by estrogen.

Estrogen regulates LGR7 (RXFP1) mRNA expression in an in vitro model of human term pregnancy cervix that utilizes lower uterine segment fibroblasts. LGR7 mRNA levels were increased by estradiol to mean levels of 152%+/- 5.9% above those in untreated control cells. Therefore, estradiol may amplify relaxin's actions in the cervix.

Expression of LGR7 in the primate corpus luteum implicates the corpus luteum as a relaxin target organ.

In women, the corpus luteum is the source of circulating relaxin. No previous studies have addressed whether the corpus luteum is also a relaxin target organ. We determined relaxin receptor LGR7 mRNA expression in human term pregnancy corpora lutea and nonhuman primate corpora lutea obtained during the menstrual cycle. Real-time reverse transcription-PCR demonstrated the expression of LGR7 mRNA in both human and rhesus monkey corpora lutea. Rhesus monkey corpora lutea were obtained from naturally cycling animals following documented luteinizing hormone (LH) surges at early, mid-, mid-late, and late luteal phases. Luteal expression of LGR7 mRNA did not show temporal variation. Since the primate corpus luteum is LH dependent, we assessed LGR7 mRNA expression in corpora lutea from rhesus monkeys treated with a gonadotropin-releasing hormone (GnRH) antagonist, which significantly suppressed pituitary LH levels. GnRH antagonist treatment, which also inhibits both progesterone and relaxin production, resulted in a fivefold increase in luteal LGR7 mRNA expression. These data suggest that luteal LGR7 mRNA expression may be regulated by relaxin and/or LH and that the primate corpus luteum is a target organ for relaxin.

Antral follicle count is a significant predictor of livebirth in in vitro fertilization cycles.

In the first published demonstration that the antral follicle count (AFC) predicts live birth after in vitro fertilization-embryo transfer (IVF-ET), we found that an AFC of >or=11 was a strong positive predictor of live birth. The AFC should not be used to exclude women from IVF treatment; however, it is a very useful instrument for patient counseling and determining appropriate treatment protocols and gonadotropin dosing in IVF cycles.

Adenomyosis a variant, not a disease? Evidence from hysterectomized menopausal women in the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: Our study evaluates the symptoms commonly attributed to adenomyosis in women undergoing the menopausal transition. We hypothesized that adenomyosis is more commonly seen in women with fibroids, pelvic pain, abnormal uterine bleeding, and in the presence of endometriosis. DESIGN: Retrospective cohort. SETTING: Multisite community-based study. PATIENT(S): Enrollees in the Study of Women's Health Across the Nation who had hysterectomies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Relationship of adenomyosis to presenting symptoms and other patient characteristics. RESULT(S): Adenomyosis was found in 48% of 137 patients. Frequencies of presenting symptoms were similar in those with and without evidence of adenomyosis. The same prevalence of fibroids was seen in the presence or absence of adenomyosis: 37% versus 43%, endometriosis, 3% versus 5%, abnormal bleeding, 27% versus 33%, or chronic pelvic pain in the presence of fibroids 12% versus 17%. CONCLUSION(S): Adenomyosis is a common diagnosis seen in hysterectomized specimens from women undergoing the perimenopausal transition. Adenomyosis is equally common in women who also have fibroids, endometriosis, pelvic pain, or abnormal uterine bleeding, and women who do not. Therefore, adenomyosis is an incidental finding, not the source of the symptomatology. It appears not to be a "disease" per se but rather a normal variant.

Ovarian reserve screening: what the general gynecologist should know.

Ovarian reserve tests are an indirect measurement of a woman's remaining follicular pool and give an estimate of her sensitivity to ovarian stimulation and her prognosis for success with fertility treatments. They cannot be used to predict future fertility or the exact timing of the decline or cessation of fertility. It is important to become familiar with these tests and understand their correct performance and interpretation, including their limitations. We review the correct timing and interpretation of the most commonly accepted tests of ovarian reserve, and suggest which patient populations will benefit most from screening. Discussed in detail are the natural age-related decline in fecundity, basal follicle stimulating hormone and estradiol levels, the clomiphene citrate challenge test, and use of transvaginal ultrasound for antral follicle counts. Other tests, such as for ovarian volume, anti-Müllerian hormone, gonadotropin-releasing hormone agonist and exogenous follicle-stimulating hormone, are discussed briefly.

A laparoscopic simulator tool for objective measurement of residents' laparoscopic ability.

OBJECTIVE: We sought to develop an objective measurement of residents' laparoscopic ability by using a laparoscopic simulator assessment tool. METHODS: An inexpensive laparoscopic simulator was developed. Three laparoscopic assessment procedures were created: 1) bead/pom-pom drop, 2) checkerboard drill, and 3) bead manipulation. Two minimally invasive surgeons and 8 PGY 3/4 and 15 PGY 1 residents were timed performing the 3 procedures. Ten of the PGY 1 residents were retested at the end of their PGY 1 year. RESULTS: The minimally invasive surgeons completed the laparoscopic drills in approximately half the time of the PGY 3/4 (P=0.02), and PGY 3/4 were 60% faster than PGY 1 (P=0.01). PGY 1 completed the drills in half the time at the end of the PGY 1 year (P=0.005). As an objective measurement of residents' laparoscopic surgery competency, by the completion of the academic year, all PGY 1 residents must be able to complete the drills as fast as or faster than the original PGY 3/4 times. CONCLUSION: We developed an inexpensive, objective, simple laparoscopic simulator assessment tool for measurement of residents' laparoscopic ability.

Stabilization and regression of a recurrent desmoid tumor with the antiestrogen toremifene.

OBJECTIVE: To report a case of a pelvic desmoid tumor that was treated with the antiestrogen toremifene after a failed attempt at surgical excision. DESIGN: Case report. SETTING: University reproductive endocrine practice. PATIENT(S): A reproductive-aged woman with a recurrent desmoid tumor. INTERVENTION(S): After surgical excision of a desmoid tumor that presented during childbirth, subsequent recurrence resulted in the use of toremifene for tumor stabilization. MAIN OUTCOME MEASURE(S): Magnetic resonance imaging was used to monitor desmoid tumor size. RESULT(S): One year after postsurgical recurrence of the desmoid tumor, the patient began treatment with the antiestrogen toremifene. Tumor stabilization and regression with symptomatic relief was observed. Nine years of antiestrogen use revealed no progression in tumor size or patient symptoms. After the patient demonstrated perimenopausal symptoms, toremifene administration was discontinued without a return of symptoms or tumor growth after 3 years. CONCLUSION(S): Our case demonstrates that toremifene is a safe and effective therapy that can be used for the stabilization and regression of desmoid tumors. An antiestrogen should be considered as adjuvant therapy after surgery and as a first-line treatment with disease recurrence. Discontinuation of antiestrogen therapy was shown to be done safely after the patient started to show signs of decreased endogenous estrogen production.

Carboplatin and paclitaxel for the treatment of advanced or recurrent endometrial cancer.

OBJECTIVE: The purpose of this study was to determine the activity and toxicity of carboplatin and paclitaxel (taxol) in the treatment of advanced or recurrent endometrial cancer. STUDY DESIGN: This was a retrospective review of 18 consecutive patients with advanced (stage 4) or recurrent endometrial adenocarcinoma that had been treated with outpatient carboplatin and taxol. Taxol was delivered at 135 mg/m 2 over 3 hours, and carboplatin was delivery at an area under the curve of 5 over 1 hour. Cycles were repeated every 21 days. RESULTS: The overall response rate was 63% with 28% of patients who had a partial response and 35% of patients who had a complete response. Kaplan-Meier test was used to estimate the median survival time of 27 months and the median progression free survival time of 24 months. No patient had neutropenia, thrombocytopenia or grade 3 vomiting, neurosensory toxicity, or renal toxicity. CONCLUSION: Carboplatin and taxol for the treatment of advanced or recurrent endometrial cancer appear to be active regimens with minimal toxicity.