Diagnosis and Management of an Adenomatoid Uterine Tumor: Ultrasound, Magnetic Resonance Imaging, Surgical Appearance, and Pathology Correlation.

Adenomatoid uterine tumors are rare, and their appearance on medical imaging modalities is not well established. We present a case of an adenomatoid uterine tumor reviewing a unique sonographic presentation, magnetic resonance imaging (MRI), gross surgical appearance of the tumor, and microscopic pathology images. A 29-year-old gravida 0 Caucasian woman presented with dysmenorrhea, menorrhagia, and desire to conceive. Transvaginal ultrasound revealed a 2.7 cm round, well-circumscribed posterior intramural uterine mass. The mass was hyperechoic centrally with a thin hypoechoic rim. Color Doppler imaging revealed a prominent vascular rim around the periphery of the mass as well as central vascularity not typical for a leiomyoma. MRI, with and without intravenous gadolinium, was obtained showing a 2.7 cm posterior fundal mildly enhancing uterine mass suggestive of leiomyoma. The mass had a heterogeneous signal pattern on T2-weighted images, and no fat component was noted within the mass. Repeat transvaginal ultrasound showed interval growth of the mass to 3.5 cm with a lipomatous appearance. Adenomatoid uterine tumors are rare and may be mistaken for uterine leiomyomata. Unique features include sonographic appearance of central hyperechogenicity with a hypoechoic rim and prominent peripheral and central vascularity in conjunction with MRI revealing a heterogeneous signal pattern on T2-weighted images without fat component. Gross surgical appearance reveals a nondiscrete capsule and secretion of mucoid material when the mass is exposed. We present a case of adenomatoid tumor providing sonographic, MRI, surgical, and pathological correlation. The patient subsequently conceived spontaneously and delivered at term by cesarean section. The patient underwent a preoperative evaluation with complete blood count, comprehensive metabolic panel, blood type with antibody screen, and pregnancy test. She underwent laparoscopic excision with robotic assistance for removal of the tumor. Grossly, the uterine mass had a very soft consistency atypical for a uterine leiomyoma making dissection more challenging. During dissection the mass diffusely secreted a mucoid material although the capsule was not disrupted. The lesion was excised intact and was removed from the peritoneal cavity in an endocatch bag without internal morcellation. Microscopic examination revealed an adenomatoid tumor.

Effects of a Delphi consensus acupuncture treatment protocol on the levels of stress and vascular tone in women undergoing in-vitro fertilization: a randomized clinical trial protocol.

BACKGROUND: The variability of published acupuncture protocols for patients undergoing In-Vitro Fertilization (IVF) complicates the interpretation of data and hinders our understanding of acupuncture's impact. In 2012, an acupuncture treatment protocol developed by a Delphi consensus process was published to describe the parameters of best practice acupuncture for Assisted Reproductive Technology and future research. However, there has been no clinical trial utilizing this protocol to assess the effects of acupuncture. This study aims to assess the implementation of Dephi consensus acupuncture protocol and to examine the impact of acupuncture on stress and uterine and ovarian blood flow among women between ages 21-42 years seeking IVF. METHODS/DESIGN: This study is a one site prospective, two-arm randomized controlled non-blind clinical trial conducted in a medical school-affiliated fertility center . Participants will be randomized 1:1 into either the acupuncture group or the standard of care (no acupuncture) group using computer generated tables. Both groups will have 3 regular clinical visits as their standard IVF care during an approximately 2 to 3 weeks window. Women who are randomized into the acupuncture group would receive three sessions based on the Delphi consensus acupuncture protocol in addition to the standard care. The first treatment will be administered between days 6 to 8 of the stimulated IVF cycle. The second session will be performed on the day of embryo transfer at least 1 h prior to the transfer. The third session will be performed within 48 h post-embryo transfer. Participants will be followed for their pregnancy test and pregnancy outcome when applicable. The outcomes stress and blood flow will be measured by a validated perceived stress scale and vasoactive molecules, respectively. DISCUSSION: Although recruitment and scheduling could be challenging at times, the Delphi consensus acupuncture protocol was implemented as planned and well-accepted by the patients. Because of the time-specified sessions around patients' IVF cycle, it is highly recommended to have on-site study acupuncturist(s) to accommodate the schedule. TRIAL REGISTRATION: ClinicalTrials NCT02591186 registered on October 7, 2015.

Is superfertility associated with recurrent pregnancy loss?

PROBLEM: A recent hypothesis has implicated superfertility as a cause of recurrent pregnancy loss. Clinical support for the concept comes from one report that 40% of women experiencing recurrent miscarriages had monthly fecundity rates of 60% or greater and thus were designated as superfertile. METHODS OF STUDY: To confirm or refute this finding, clinical histories of 201 women with a history of recurrent pregnancy loss were reviewed and months to desired pregnancy, karyotypes of their products of conception as well as results of laboratory tests including antiphospholipid antibodies and circulating natural killer cells were recorded. RESULTS: The prevalence of superfertility was 32% (64/201) among recurrently aborting women compared with 3% of the general population according to the model of Tietze (P < 0.0001). Fifty-nine of the 201 (30%) study patients displayed presence of APA,LA, increased CD56(+) cells, or increased NK cytotoxicity and were designated as having an immunologic risk factor. Of the 192 karyotypes of products of conception from women with a history of recurrent miscarriage, 153 (80%) had a normal chromosome complement and 38 (20%) were abnormal. Among the normal karyotypes, 86 (56%) were 46XX and 67 (44%) were 46XY. CONCLUSION: Recurrent pregnancy loss is associated with superfertility in 32%, immunologic risk factors in 30% and a 20% frequency of chromosomally abnormal pregnancy losses. Thus, implantation failure can result from too much or too little implantation.