Effects of early endometriosis on IVF-ET outcomes.

There have been very few reports on the outcomes of in vitro fertilization and embryo transfer (IVF-ET) in women with stage I/II endometriosis. The objective of this study was to investigate IVF-ET outcomes in women with early-stage endometriosis. We enrolled 35 women less than 40 years with unexplained infertility who underwent IVF-ET into the study. We compared 18 women with stage I/II endometriosis according to the revised American Society for Reproductive Medicine classification for endometriosis, who underwent 39 IVF-ET cycles (En (+) group) with 17 women without endometriosis who underwent 41 IVF-ET cycles (En (-) group). Higher requirements of total gonadotropin, a lower percentage of high-quality embryos of all fertilized eggs (9.0% vs. 16.3%), a relatively lower pregnancy rate (33.3% vs. 41.5%), and a lower live birth rate (25.6% vs. 34.1%) were observed in the En (+) group. Although no significant effect on IVF-ET outcome was observed, ovarian response may be decreased in women with stage I/II endometriosis. Considering the decreased number of high-quality embryos in the En (+) group, stage I/II endometriosis may have detrimental effects on embryo quality.

Acute congestive heart failure due to ruptured mitral chordae tendineae in late pregnancy.

A 31-year-old woman complained of dyspnea and orthopnea at 38 weeks of gestation. A grade 3/6 pansystolic murmur was heard, and echocardiography revealed severe mitral regurgitation with a hyperechoic obstacle on the posterior mitral valve leaflet, consistent with a diagnosis of acute heart failure due to a ruptured chordae tendineae or an infectious endocarditis. An emergency cesarean section was performed under general anesthesia. A male infant was born weighing 2928 g with Apgar scores of 7 and 8 at 1 and 5 min, respectively. The patient was managed in the intensive care unit and underwent open-heart surgery for mitral valve repair on postpartum day 3. The two chordal tendineae appeared torn and frail, and a mitral annuloplasty was performed. No finding of infectious endocarditis was observed. Because it is a dramatic and life-threatening clinical situation, proper diagnosis and treatment in the intensive care unit assure a good outcome for both mother and fetus.

Comparison between the gonadotropin-releasing hormone antagonist protocol and the gonadotropin-releasing hormone agonist long protocol for controlled ovarian hyperstimulation in the first in vitro fertilization-embryo transfer cycle in an unspecified population of infertile couples.

PURPOSE: We aimed to compare the efficacy of a gonadotropin-releasing hormone (GnRH) antagonist protocol and a GnRH agonist long protocol used in the first in vitro fertilization-embryo transfer (IVF-ET) cycle in an unspecified population of infertile couples. METHODS: Fifty and 34 patients were treated with a GnRH agonist long protocol (agonist group) and GnRH antagonist protocol (antagonist group), respectively, in the first treatment cycle. The primary and secondary outcome measures were cumulative live birth rates after fresh and cryopreserved-thawed ETs and incidence of grades II and III ovarian hyperstimulation syndrome (OHSS), respectively. RESULTS: No significant differences were observed in clinical pregnancy rates (38.0 vs. 32.4%) and live birth rates (22.0 vs. 23.5%), which included both fresh and cryopreserved-thawed ETs, between the 2 groups. However, the incidence of grade III OHSS was significantly lower with the GnRH antagonist protocol than the GnRH agonist long protocol. CONCLUSIONS: Used in the first IVF-ET cycle in an unspecified population of infertile patients, the GnRH antagonist protocol showed the same clinical outcome as the GnRH agonist long protocol.

Hysteroscopic tubal catheterization under laparoscopy for proximal tubal obstruction.

PURPOSE: The purpose of this study was to investigate the fertility outcomes of infertile patients having proximal tubal obstruction treated with hysteroscopic tubal catheterization (HCT) for recanalization under diagnostic laparoscopy. METHODS: From January 2000 to December 2008, diagnostic laparoscopy was used to assess the tubal status of 61 patients with unilateral or bilateral proximal tubal obstruction, as confirmed by hysterosalpingography. Among them, 35 patients with tubal obstruction confirmed by chromopertubation under laparoscopy subsequently underwent HCT. The pregnancy outcomes and success rates of recanalization were investigated. RESULTS: In the 35 patients with confirmed tubal obstruction, HCT was performed in 54 fallopian tubes. The success rate of recanalization was 25.9% (14/54) per tube and 37.1% (13/35) per patient. Of the patients in whom tubal patency was restored, 4 achieved pregnancy, including 1 tubal pregnancy and 1 miscarriage. Among the 61 patients, excluding 14 who underwent in vitro fertilization-embryo transfer (IVF-ET) after laparoscopy, 13 were pregnant (27.7%), 9 gave live births, 1 had tubal pregnancy, and 3 had miscarriages. CONCLUSIONS: HCT under laparoscopy is an option for couples with tubal infertility who do not prefer IVF-ET.

Rupture of pseudoaneurysm after vaginal delivery successfully treated by selective arterial embolization.

BACKGROUND: Rupture of a pseudoaneurysm after vaginal delivery is a rare cause of postpartum hemorrhage. CASE: A 29-year-old primigravida delivered a healthy boy by vacuum extraction at 38 weeks of gestation. The patient underwent repair of a right mediolateral episiotomy and left vaginal wall laceration. On the third postpartum day she experienced massive vaginal bleeding with vaginal wall laceration, and the vaginal bleeding progressively increased. A selective angiogram of the left internal iliac artery showed a pseudoaneurysm with extravasation originating from the left internal pudendal artery. Complete occlusion of the pseudoaneurysm was achieved by embolization of the left internal pudendal artery. The postprocedural course was uneventful. CONCLUSION: A pseudoaneurysm should be considered in unclear cases of postpartum hemorrhage.

Warfarin-associated fetal intracranial hemorrhage in woman with mitral valve replacements: a case report.

Warfarin-associated fetal hemorrhage is a fatal event. We report the case of a 39-year-old woman who had been taking warfarin for 23 years since undergoing mitral valve replacement. Thereafter, when she was found to be pregnant, the medication was switched to heparin from 6 to 21 weeks of gestation. Following this, she was prescribed oral warfarin again (3.5 mg per day), with a strict control of prothrombin time/international normalized ratio (PT/INR). At 23 weeks of gestation, fetal intracranial hemorrhage occurred because of maternal exposure to warfarin. Maternal PT/INR does not correlate well with the activity of warfarin in the fetus and currently, there is no direct way to prevent fetal intracranial hemorrhage. Hence, further research on the optimal coagulation therapy in pregnant women with valve replacement should be encouraged.

Elective use of aortic balloon occlusion in cesarean hysterectomy for placenta previa percreta.

BACKGROUND: Only few reports are available on the use of aortic balloon catheter for cesarean hysterectomy in placenta previa percreta. CASE: A 32-year-old woman with placenta previa percreta underwent cesarean hysterectomy at 34 weeks of gestation. Before starting the surgery, an aortic occlusion balloon catheter (30 mm balloon, 5 Fr) was inserted. For total hysterectomy, the aortic balloon catheter was inflated and there was a sudden and dramatic reduction in blood loss, and the surgery was completed safely. An aortic occlusion was sustained for 80 min, with blood loss estimated at 3,200 ml. The postoperative course was uneventful. At 3 months after the operation, the mother and baby remained healthy. CONCLUSION: An aortic balloon is rapidly and easily inserted, and is an option for major hemorrhage in placenta previa percreta.

Thyroid function after hysterosalpingography using an oil-soluble iodinated contrast medium.

BACKGROUND: The objective of the present study was to evaluate the effect of an oil-soluble iodinated contrast medium (lipiodol) for hysterosalpingography (HSG) on thyroid function. METHODS: In 214 of 528 women with infertility examined by HSG using lipiodol between 1996 and 2006 at our institution, serum free thyroxine (FT4) and thyrotropin-stimulating hormone (TSH) were measured before and several months after HSG. RESULTS: The average age of the women was 34.5 +/- 4.6 years and their average infertility period was 2.9 +/- 2.5 years (mean+/-standard deviation). The 214 patients were divided into three groups based on the results of thyroid function before HSG: 180 in euthyroid, 28 in subclinical hypothyroidism and 13 in subclinical hyperthyroidism. The number of patients in the subclinical hypothyroidism group who developed hypothyroidism after HSG (ten of 28) was significantly higher than that of the euthyroid group (four of 180). Thyroid hormone replacement was required in three patients from the subclinical hypothyroidism group 1, 2 and 5 months after HSG. CONCLUSIONS: We conclude that thyroid function should be monitored closely after HSG using lipiodol to detect the development of hypothyroidism, particularly in patients with subclinical hypothyroidism, and TSH and FT4 measurements should be performed before HSG to identify patients at risk for hypothyroidism.

Outcome of pregnancy after laser conization: implications for infection as a causal link with preterm birth.

OBJECTIVE: To investigate a causal link between infection and preterm birth in women with a shortened cervix induced by prior laser conization. METHODS: We conducted a retrospective review of the outcomes of 47 singleton pregnancies with a history of laser conization. Cervical length was measured between 17 and 23 weeks of gestation. Receiver-operating characteristic curves were used to determine the best cut-off point for the cervical length for predicting spontaneous preterm birth. We measured infectious markers in 12 women who had experienced preterm labor. RESULTS: Nine women had had premature labors and three had had late abortions. The mean +/- SD cervical length was 33.1+/-9.1 mm. The optimal cut-off for predicting preterm delivery was 25 mm with a sensitivity and specificity of 75.0% and 97.1%, respectively. Concentrations of granulocyte elastase were positive in five of the six samples determined. The white blood cell count and C-reactive protein levels were elevated in four out of the six patients. Sixty-seven percent of the vaginal cultures were positive for bacteria. Chorioamnionitis was present in seven women. CONCLUSIONS: For the prediction of preterm birth in patients with a history of conization, it is helpful to look for signs of local infection when the cervical length is less than 25 mm.

Concurrent chemoradiation for locally advanced squamous cell carcinoma of the vagina: case series and literature review.

BACKGROUND: We reviewed our experience with patients with primary squamous cell carcinoma of the vagina who received concurrent chemoradiation therapy (CCRT). METHODS: We retrospectively analyzed six patients (median age, 60 years) with squamous cell carcinoma of the vagina who underwent CCRT between 2002 and 2005 at the University of the Ryukyus Hospital. Two patients were in International Federation of Obstetricians and Gynecologists (FIGO) stage II, one in stage III, and three in stage IVA. All patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or less. Tumor size ranged from 3.2 to 7.7 cm. All patients were treated with true pelvic external-beam radiotherapy (EBRT) at 50 Gy. Then two of the six patients underwent intracavitary vaginal brachy-therapy. The remaining four patients received boost EBRT with shrinking fields. Total radiation dose to the vaginal tumor ranged from 60 to 66 Gy. All patients received two or three concomitant cycles of cisplatin during EBRT. RESULTS: All six patients completed their scheduled CCRT, and achieved a clinical complete response. One stage II patient died of disease 24 months after treatment, and the stage III patient had local failure at 12 months. The remaining four patients were free of their disease at 18, 23, 33, and 55 months, respectively. One patient with stage IVA developed a vesicovaginal fistula during CCRT. Nevertheless, CCRT was well tolerated by all six patients, and no grade 3 or 4 late toxicity was observed, as evaluated by the Radiation Therapy Oncology Group (RTOG) scoring system. CONCLUSION: CCRT is effective for primary squamous cell carcinoma of the vagina and should be considered for treatment in patients with high-risk disease having good performance status.

Laparoscopic marsupialization of pelvic lymphocele under transvaginal ultrasonographic guidance.

Lymphocyst formation is a common complication of pelvic lymphadenectomy. We treated a 54-year-old woman with lymphocele by laparoscopic marsupialization. She developed hydronephrosis as a result of retroperitoneal lymphocele after total abdominal hysterectomy and pelvic lymphadenectomy for endometrial cancer. Laparoscopic marsupialization under transvaginal ultrasonographic guidance was chosen because conservative therapy including percutaneous or transvaginal drainage ran the risk of bowel perforation. The 6-cm collection was opened and its edges were coagulated electrosurgically and sutured with the surrounding peritoneum. The postoperative course was satisfactory, and hydronephrosis was resolved. This highly effective minimally invasive procedure was beneficial to the patient.

Squamous cell carcinoma arising in an ovarian mature cystic teratoma complicating pregnancy: a case report.

BACKGROUND: The question of whether patients with pure stage I squamous cell carcinoma in a mature cystic teratoma (MCT) should undergo conservative surgery, or postoperative adjuvant treatment remains unresolved. CASE: A 33-year-old woman with a left ovarian cyst underwent laparoscopic cystectomy at 16 weeks of gestation. Histological examination confirmed squamous cell carcinoma arising in an MCT. At 18 weeks of gestation, she underwent left salpingo-oophorectomy, and was diagnosed as having stage Ic malignant transformation of the MCT, and was observed closely without postoperative adjuvant chemotherapy. She delivered a healthy baby at 41 weeks of gestation. No evidence of recurrence was observed 14 months after the initial laparoscopic surgery. CONCLUSION: Although a thorough staging procedure , histopathologic evaluation, and long-term follow-up are indispensable, patients with early stage I squamous cell carcinoma in MCT may safely undergo conservative surgery.

Effectiveness of comprehensive supports for schizophrenic women during pregnancy and puerperium: preliminary study.

The risks of deteriorated psychiatric symptoms/daily life functioning should be warned of in schizophrenic women during pregnancy and puerperium. The purpose of the present paper was to prospectively monitor mental status and functioning of pregnant women with schizophrenia, and investigate the effects of various supports. Subjects were 20 schizophrenic women who visited a clinic providing care and support for pregnant women with psychiatric diseases, consisting of 12 patients with psychotic deterioration (deterioration group) and eight remitted stable patients (stable group). Psychiatric assessments were performed using Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) at three time-points: at the first examination, after fixed prescription during pregnancy, and after delivery. The types/doses of drugs and other non-drug-related supports (13 items) were recorded during the study period. Although a higher total PANSS score at the first examination (P = 0.004) and lower GAF scores at the first examination and even after fixed prescription (P = 0.0003) were observed in the deterioration group, those after delivery finally caught up with the levels in the stable group. Doses of antipsychotic drugs were gradually increased in the deterioration group although no significant differences in chlorpromazine equivalent doses were found between the two groups after fixed prescription. There was a positive correlation between the number of non-drug-related supports and amelioration score in PANSS (r(s) = 0.553, P = 0.012). These findings suggest that comprehensive intervention is a requisite in pregnant schizophrenic women, especially with psychotic deterioration, and that non-drug-related supports may also contribute to maintenance of good and stable mental status in these patients.

A case of congenital high airway obstruction syndrome managed by ex utero intrapartum treatment: case report and review of the literature.

Congenital high airway obstruction syndrome (CHAOS) has been reported to be fatal. Ten cases of CHAOS that underwent ex utero intrapartum treatment (EXIT) procedure to secure the fetal airway have been reported. A 36-year-old woman (gravida 3, para 2) was referred to our hospital at 22 weeks of gestation. Sonography revealed large echogenic lungs, flattened diaphragm, and marked hydrops. Magnetic resonance imaging confirmed the diagnosis of CHAOS. Polyhydramnios and fetal skin edema were improved and the fetal ascitic fluid was regressed gradually. At 36 weeks of gestation, an EXIT procedure was undertaken. Fetal laryngoscopy and bronchoscopy showed complete laryngeal obstruction, and a tracheostomy was performed immediately. The infant was discharged from hospital at 6 weeks of age. Thereafter, he developed well both physically and mentally. A laryngoplasty was performed at 20 months of age using silicon sheet as a patent airway. The child has a tracheostomy, is able to phonate but does not speak, and is awaiting decannulation. Use of the EXIT procedure in CHAOS cases offers the potential for salvage and excellent long-term outcome of these fetuses that otherwise would not survive. However, management of the airway, particularly with regard to long-term reconstruction in children with CHAOS, remains challenging.

Primary omental gestational choriocarcinoma ascertained by deoxyribonucleic acid polymorphism analysis.

BACKGROUND: Abdominal choriocarcinoma is extremely rare. It is important to examine whether the disease is primary or metastatic and gestational or non-gestational. CASE: A 26-year-old nulli-gravid woman underwent laparoscopy for presumed ectopic pregnancy. The uterus, ovaries and fallopian tubes surrounded by hemoperitoneum were unremarkable. A hemorrhagic 7-cm-sized tumor was identified on the greater omentum and excised. Histology was consistent with choriocarcinoma. Analysis of human leucocyte antigen (HLA) gene polymorphism on deoxyribonucleic acid (DNA) demonstrated that tumor DNA contained both HLA locus antigens of patient and of her husband. Clinical remission was achieved with six courses of chemotherapy. CONCLUSION: To our knowledge, this is the first reported case of choriocarcinoma that occurred primarily on the omentum ascertained to be of gestational origin by DNA polymorphism analysis.

Combination external beam radiotherapy and high-dose-rate intracavitary brachytherapy for uterine cervical cancer: analysis of dose and fractionation schedule.

PURPOSE: To determine an appropriate dose and fractionation schedule for a combination of external beam radiotherapy (EBRT) and high-dose-rate intracavitary brachytherapy (HDR-ICBT) for uterine cervical cancer. METHODS: Eighty-eight patients with uterine cervical squamous cell carcinoma treated with EBRT and HDR-ICBT were analyzed. Twenty-five patients were classified as early disease (nonbulky Stage I/II, less than 4-cm diameter) and 63 patients as advanced disease (greater than 4 cm diameter or Stage IIIB) according to the American Brachytherapy Society definition. Tumor diameter was measured by MRI. Pelvic EBRT was delivered before applications of ICBT. HDR-ICBT was performed once a week, with a fraction point A dose of 6 Gy. Source loadings corresponded to the Manchester System for uterine cervical cancer. No planned optimization was done. A Henschke-type applicator was mostly used (86%). Median cumulative biologic effective dose (BED) at point A (EBRT + ICBT) was 64.8 Gy(10) (range: 48-76.8 Gy(10)) for early disease, and 76.8 Gy(10) (range: 38.4-86.4 Gy(10)) for advanced disease. Median cumulative BED at ICRU 38 reference points (EBRT + ICBT) was 97.7 Gy(3) (range: 59.1-134.4 Gy(3)) at the rectum, 97.8 Gy(3) (range: 54.6-130.4 Gy(3)) at the bladder, and 324 Gy(3) (range: 185.5-618 Gy(3)) at the vagina. Actuarial pelvic control rate and late complication rate were analyzed according to cumulative dose and calculated BED. RESULTS: The 3-year actuarial pelvic control rate was 82% for all 88 patients: 96% for those with early disease, and 76% for advanced disease. For pelvic control, no significant dose-response relationship was observed by treatment schedules and cumulative BED at point A for both early and advanced disease. The 3-year actuarial late complication rates (Grade > or =1) were 12% for proctitis, 11% for cystitis, and 14% for enterocolitis. There were significant differences on the incidence of proctitis (p < 0.0001) and enterocolitis (p < 0.0001), but not for cystitis by the treatment schedules and cumulative point A BED. All 4 patients treated with 86.4 Gy(10) at point A suffered both proctitis and enterocolitis. Patients with cumulative BED at rectal point of > or =100 Gy(3) had significantly higher incidence of proctitis (31% vs. 4%, p = 0.013). CONCLUSIONS: In view of the therapeutic ratio, cumulative BED 70-80 Gy(10) at point A is appropriate for uterine cervical cancer patients treated with a combination of EBRT and HDR-ICBT. Present results and data from other literatures suggested that cumulative BED at the rectal point should be kept below 100-120 Gy(3) to prevent late rectal complication.

Management of invasive carcinoma of the uterine cervix associated with pregnancy: outcome of intentional delay in treatment.

OBJECTIVE: To investigate patients with invasive cervical carcinoma associated with pregnancy, with special reference to the maternal and neonatal outcomes after planned treatment delay to improve fetal maturity. METHODS: The medical records of 28 patients with invasive cervical carcinoma diagnosed during pregnancy or within 1 month after pregnancy were retrospectively reviewed. RESULTS: Twenty-two patients (79%) had Stage I disease and 6 (21%) had Stage II or III disease. Tumor histology revealed squamous cell carcinoma in 27 cases and adenocarcinoma in 1. Twenty cases were diagnosed before 22 weeks gestation, 4 between 22 and 36 weeks, 1 after 36 weeks gestation, and 3 were diagnosed postpartum. In the immediate treatment group (n = 16), the diseases were Stage IA in 3 cases, IB in 7, and II or III in 6. In 11 patients, hysterectomy was performed after therapeutic abortion or with fetus in situ. In 2 patients, cesarean section was followed by hysterectomy or radiotherapy. Three patients diagnosed postpartum were treated with either hysterectomy or radiotherapy. Fifteen patients were free of disease during the follow-up of 27 to 114 months. In the delayed treatment group (n = 12), the diseases were Stage IA1 in 8 cases, IA2 in 1, IB1 in 2, and IB2 in 1 case. In 8 patients with Stage IA1 tumor, the treatment was deferred until term with a delay of 6 to 25 weeks, and hysterectomy or therapeutic conization was performed after delivery. In 4 patients with Stage IA2, IB1 or IB2 tumor, the treatment was postponed until after 30 weeks gestation with a delay of 6 to 15 weeks. No disease progression was documented. Cesarean delivery was followed by hysterectomy in these patients. All patients were free from disease during the follow-up of 70 to 156 months and their babies were well with no sequelae. CONCLUSION: Delay in treatment to allow for fetal maturity is safe in patients with early Stage I cervical carcinoma associated with pregnancy.

High dose-rate intracavitary brachytherapy for carcinoma in situ of the vagina occurring after hysterectomy: a rational prescription of radiation dose.

OBJECTIVE: Our purpose was to profile patients who were treated with high dose-rate intracavitary brachytherapy for carcinoma in situ of the vagina that occurred after hysterectomy, with special reference to a rational prescription of radiation dose. STUDY DESIGN: We reviewed 13 patients who were treated for posthysterectomy carcinoma in situ of the vagina by the brachytherapy as the sole treatment. The brachytherapy was delivered by a remote-controlled afterloading intracavitary radiation system. RESULTS: The mean age of the patients was 62 years. The total dose of absorbed radiation was 36 and 30 Gy that was prescribed at 1.0-cm depth to the vaginal surface in 3 cases and at 40 and 30 Gy that was prescribed at 0.5-cm depth in 10 cases. All patients had vaginal mucosal radiation changes of mild to moderate grade. Three cases that were irradiated to a total dose of 30 Gy at 1.0-cm depth had rectal bleeding and/or macroscopic hematuria. Complaints regarding sexual functioning were not found in this retrospective analysis. All patients remain free of disease after a median follow-up period of 127 months. CONCLUSION: High dose-rate brachytherapy with a dose prescription at 0.5-cm depth can yield a promising rate of tumor control, with lower associated morbidity than that with a dose prescription at 1.0-cm depth in the treatment of posthysterectomy carcinoma in situ of the vagina.