Interstitial and Cornual Ectopic Pregnancy: Conservative Surgical and Medical Management

Background

Interstitial and cornual ectopic pregnancy is rare, accounting for 2–4% of ectopic pregnancies and remains the most difficult type of ectopic pregnancy to diagnose due to low sensitivity and specificity of symptoms and imaging. The classic triad of ectopic pregnancy—abdominal pain, amenorrhea and vaginal bleeding—occurs in less than 40% of patients. The site of implantation in the intrauterine portion of fallopian tube and invasion through the uterine wall make this pregnancy difficult to differentiate from an intrauterine pregnancy on ultrasound. The high mortality in this type of pregnancy is partially due to delay in diagnosis as well as the speed of hemorrhage.

Methods

Three cases of interstitial pregnancy were retrospectively analyzed.

Result

Successful laparoscopic cornuostomy and removal of products of conception were performed in two cases, while one case was successfully managed by local injection with KCL and methotrexate followed by systemic methotrexate.

Conclusion

Early diagnosis and timely management are key to the management of interstitial and cornual ectopic pregnancy. With expertise in ultrasound imaging and advances in laparoscopic skills progressively, conservative medical and surgical measures are being used to treat interstitial and cornual ectopic pregnancy successfully.

     

Effect of intrauterine injection of human chorionic gonadotropin before fresh embryo transfer on IVF and ICSI outcomes: a meta-analysis

Purpose

This analysis was performed to evaluate the effects of intrauterine injection of human chorionic gonadotropin (hCG) before fresh embryo transfer (ET) on the outcomes of in vitro fertilization and intracytoplasmic sperm injection.

Methods

Randomized controlled trials (RCTs) were identified by searching electronic databases. The outcomes of live birth, clinical pregnancy, implantation, biochemical pregnancy, ongoing pregnancy, ectopic pregnancy, and miscarriage between groups with and without hCG injections were analyzed. Summary measures were reported as risk ratios (RR) with 95% confidence intervals.

Results

Six RCTs on fresh embryo transfer (ET) were included in the meta-analysis. A total of 2759 women undergoing fresh ET were enrolled (hCG group n?=?1429; control group n?=?1330). Intrauterine injection of hCG significantly increased rates of biochemical pregnancy (RR 1.61) and ongoing pregnancy (RR 1.58) compared to controls. However, there were no significant differences in clinical pregnancy (RR 1.11), implantation (RR 1.17), miscarriage (RR 0.91), ectopic (RR 1.65) or live birth rates (RR 1.13) between the hCG group and control group.

Conclusion

The current evidence for intrauterine injection of hCG before fresh ET does not support its use in an assisted reproduction cycle.

     

The impact of elevated thyroid stimulating hormone on female subfertility

Purpose

Hypothyroidism is known to have a negative impact on female reproduction even in subclinical form, subclinical hypothyroidism (SH). This study aimed to investigate the association between elevated TSH level and reproductive outcome.

Methods

We retrospectively evaluated a total of 203 infertile women who first visited our infertility treatment division from January 1, 2009 to August 31, 2012, including 13 patients with TSH above 4.5 mIU/l (elevated-TSH patients), 11 of whom were diagnosed as SH, and 190 patients with normal TSH (normo-TSH patients). We evaluated them according to reproductive outcome, including clinical pregnancy, miscarriage, and live birth until April 31, 2014. We also aimed to redefine the upper limit of normal serum TSH level.

Results

Multivariate analysis showed significant influence of elevated TSH on clinical pregnancy, although miscarriage and live birth were not affected. In addition, we revealed that the rate of decreased ovarian reserve and unexplained infertility was increased in patients with elevated TSH levels.

Conclusions

We found an association between elevated TSH and the decreased rate of clinical pregnancy. This might be related to an ovulatory disorder and pathophysiology of unexplained infertility. These results may reinforce the usefulness of TSH screening in infertility population.

     

Is the yolk sac a new marker for chromosomal abnormalities in early pregnancy?

Introduction

Abnormal yolk sac size is associated with fetal miscarriage. This is a case report of two pregnancies with abnormal yolk sacs.

Materials and methods

In one case, a twofold sac was found; in the other case, the yolk sac was not of spherical form.

Conclusion

Currently available publications demonstrate a correlation between abnormal yolk sac size and miscarriage. However, in both cases a trisomy was confirmed. It should therefore be discussed whether form and size of the yolk sac could be a marker for chromosomal abnormalities of the fetus.

     

Diagnosis and management of heterotopic pregnancy following embryo transfer: clinical analysis of 55 cases from a single institution

Objective

The aims of this study were to summarize the clinical features of patients with heterotopic pregnancy (HP) following embryo transfer (ET) and explore the risk factors for miscarriage after surgery.

Methods

All patients with HP following ET treated by surgery between August 2014 and August 2015 in Chongqing Health Center for Women and Children were retrospectively reviewed.

Results

Fifty-five patients were identified, including 40 with tubal HP, 9 interstitial HP and 6 cornual HP. The most frequent manifestations before diagnosis was abdominal pain (29.1%), while 19 patients (34.5%) had no symptoms before diagnosis. The sensitivity of symptoms for HP was 65.5%. Gestational age at symptom onset of these patients with symptoms (n = 36) was 5.8 weeks (range 4.7–8.1). Forty-seven patients (85.5%) were suspected of HP when they received first transvaginal ultrasonography (TVS). The mean gestational age at diagnosis was 6.3 weeks (range 4.7–8.3, 16–41 days after ET). First TVS suggesting HP (P = 0.000) and first TVS performed before day 27 (P = 0.000) were two independent predictors for gestational age at diagnosis. Gestational age at surgery day was 6.7 weeks (range 5.3–10.7). Fifty-one patients (92.7%) resulted in a live birth. Gestational age at surgery day was the only independent risk factor for miscarriage in patients with HP treated by laparotomy (OR 0.003, 95% CI 0.001–0.604).

Conclusions

Routine TVS at day 27 after ET could facilitate the diagnosis of HP, symptoms onset before or after day 27 are clues to early diagnosis. Prompt surgery after diagnosis may improve the prognosis of HP following ET.

     

Fortpflanzung im höheren Alter

Background

Pregnancies with autologous or donated oocytes above the age of 40 years are both associated with the same problems, which can be caused by the age of the women or possible alterations of the uterus, e.g. leiomyomas.

Objective and methods

In this article the influential factors and effects of advanced age on the course of pregnancy are summarized. The situation after spontaneous conception with autologous oocytes as well as the conditions after oocyte donation are discussed. This was accomplished by carrying out a literature search.

Results

Gestational diabetes, hypertension and preeclampsia develop more frequently during pregnancy in an age-dependent manner. In the case of conception with autologous oocytes the dominant problem is miscarriage, which is caused by the rate of aneuploidy of the oocytes. In the case of donor oocytes the rate of miscarriage is lower due to the younger age of the donor; however, the probability of hypertension and preeclampsia is also increased. Furthermore, psychosocial aspects are important because the natural strengths of the mother, which are necessary for caring for children decrease with age.

Conclusion

Physicians should offer older female patients or couples an intensive counseling with respect to these problems.

     

Fertility after uterine artery embolization of fibroids: a systematic review

Purpose

The impact of uterine artery embolization (UAE) for the purpose of diminishing the effect of uterine fibroids on fertility is unclear. We have investigated the reported rates of pregnancy and miscarriage after treatment of uterine fibroids with UAE.

Materials and methods

We searched for relevant information in PubMed and Embase for randomized controlled trials (RCT), controlled clinical trials, comparative before–after trials, cohort studies, case–control studies and case series where UAE treatment of premenopausal women was performed for uterine fibroids with and where a control intervention was included. The PRISMA guideline was used to do a systematic review using the main outcomes pregnancy rate and miscarriage rate. Risk of bias was assessed by the Cochrane risk of bias tool or by ROBINS-I. The quality of evidence was assessed by the GRADE approach.

Results

We included 17 studies (989 patients): 1 RCT, 2 cohort studies, and 14 case series. Pregnancy rates after UAE were 50% in the RCT and 51 and 69% in the cohort studies. Among the case series median pregnancy rate was 29%. Miscarriage rates were 64% in the RCT. Miscarriage rates at 56 and 34% were found in the cohort studies after UAE. The median miscarriage rate was 25% in the case series.

Conclusion

Pregnancy rate was found to be lower and miscarriage rate higher after UAE than after myomectomy. However, we found very low quality of evidence regarding the assessed outcomes and the reported proportions are uncertain. There is a need for improved prospective randomized studies to improve the evidence base.Systematic review registration number: CRD42016036661.

     

Successful treatment of acute promyelocytic leukemia in pregnancy with single-agent all-trans retinoic acid

Purpose

The diagnosis of acute promyelocytic leukemia (APL) in pregnancy is an uncommon, life-threatening emergency. Choice of treatment and management of complications are challenging.

Methods

We report the case of a patient with diagnosis of APL at gestational age (GA) 24 + 4. We describe the interdisciplinary management during pregnancy and delivery and provide a 2-year follow-up. Existing reports on APL in pregnancy are summarized.

Results

Single-agent induction therapy with all-trans retinoic acid (ATRA) was started and resulted in normalization of blood cell counts after 32 days. Vaginal delivery of a healthy baby occurred at GA 34 + 4. Consolidation therapy consisted of four courses of ATRA and arsenic trioxide (ATO). Less than 100 cases of APL in pregnancy are published. Misdiagnosis as HELLP syndrome with fatal outcome may occur. Combination therapies (ATRA-plus anthracyclines) were used in the majority of reports.

Conclusions

Diagnosis and treatment of APL during pregnancy continues to be a challenge requiring interdisciplinary team work. Single-agent ATRA therapy may evolve as a safe and less-toxic treatment modality.

     

Embryoscopy and karyotype findings of repeated miscarriages in recurrent pregnancy loss and spontaneous pregnancy loss

Purpose

The aim of the study was to assess cytogenetic and embryoscopic characteristics in subsequent miscarriages of spontaneous pregnancy losses (SPL) and recurrent pregnancy losses (RPL).

Methods

A retrospective cohort of 75 women was affected by repeated pregnancy loss. Of those, 34 had SPL, 24 primary RPL, and 17 secondary RPL. Ploidy status and morphology was analyzed by transcervical embryoscopic examination of the embryo and cytogenetic analysis of the chorionic villi in subsequent miscarriages.

Results

Similar rates of recurrent ploidy status were observed between first and second miscarriage in SPL and RPL (82.4% recurrent ploidy status in SPL, p?>?0.999; 73% recurrent ploidy status in RPL, p?=?0.227). No difference was found regarding recurrent abnormal morphology between SPL and RPL (p?=?0.092). However, secondary RPL resulted significantly more often in recurrent abnormal morphology compared to primary RPL (p?=?0.004).

Conclusions

High rates of recurrent normal/abnormal karyotypes were observed in all groups with a majority of embryos presenting with recurrent abnormal morphology. Secondary RPL presented significantly more often with recurrent abnormal morphology compared to primary RPL. These findings offer prognostic information for the affected patient and might impact treatment choice.

     

Morbid obesity and pregnancy outcomes after single blastocyst transfer: a retrospective,North American study

Purpose

Maternal obesity has been shown to affect reproductive function and pregnancy outcomes following in vitro fertilization. More recently, studies have demonstrated lower live birth rates after single blastocyst transfer (SBT) in patients who are overweight or obese. However, the impact of morbid obesity on pregnancy outcomes after SBT has not been well elucidated. The present study aimed to determine whether morbid obesity has a detrimental impact on pregnancy outcomes after SBT in a North American population.

Methods

A retrospective, cohort study including 520 nulliparous and multiparous women undergoing top-quality SBT between August 2010 and March 2014 at a University Health Centre in North America was conducted. Primary outcomes included: miscarriage rate, clinical pregnancy rate, and live birth rate. Subjects were divided into different BMI categories (kg/m²), including <20, 20–24.9, 25.0–29.9, 30–40, and 40 or more.

Results

The miscarriage rate per pregnancy for each group, respectively, was 36, 64, 59, 61, and 50% (p?=?0.16); the clinical pregnancy (per patient) rate per group was 36, 52, 38, 26, and 10% (p?=?0.009); and the live birth rate (per patient) per group was 35, 50, 38, 26 and 10% (p?=?0.03).

Conclusion

Morbid obesity is a strong and independent predictor of poor pregnancy outcomes in patients undergoing top-quality SBT.

     

Cumulative pregnancy and live birth rates through assisted reproduction in women 44–45 years of age: is there any hope?

Purpose

The purpose of the study is to calculate the cumulative pregnancy rate and cumulative live birth rate in women undergoing in vitro fertilization (IVF) at ages 44–45.

Methods

The study calculated cumulative live pregnancy rate and cumulative live birth rate of 124 women aged 44 to 45 years old who commenced IVF treatment.

Main outcome measures

The main outcome measures are cumulative live pregnancy rate and cumulative live birth rate.

Results

Cumulative live pregnancy rates following 1, 2, 3, and 4 cycles were 5.6, 11, 17, and 20%, respectively, with no additional pregnancies in further cycles. Cumulative live birth rates following 1, 2, and 3 cycles were 1.6, 3, and 7%, respectively, with no additional live births in further cycles.

Conclusions

The cumulative pregnancy rate rises during the first 4 cycles and cumulative live birth rate rises during the first 3 cycles, with no additional rise in pregnancies or deliveries thereafter, suggesting that it is futile to offer more than 3 cycles of treatment to 44–45-year-old women.

     

Recurrence rates after abdominal and vaginal cerclages in women with cervical insufficiency: a validated cohort study

Purpose

To estimate the incidence of cervical insufficiency and compare recurrence rates of second trimester miscarriage/delivery in second and third pregnancies after prophylactic vaginal cerclage, abdominal cerclage, or no cerclage.

Methods

Retrospective chart review of a representative register-based sample of 621 women with a spontaneous second trimester miscarriage/delivery in the first pregnancy in Denmark (1997–2012). We used strict criteria for the diagnosis of cervical insufficiency. The outcome of subsequent pregnancies was described by treatment with prophylactic vaginal cerclage, abdominal cerclage, or no prophylactic cerclage. Women were followed until June 2015.

Results

Of 621 women, 149 (24%) fulfilled the strict criteria of cervical insufficiency. Prophylactic treatment with abdominal cerclage (n?=?20), vaginal cerclage (n?=?59), and no prophylactic cerclage (n?=?61) resulted in a second pregnancy ending before 28 weeks in 5, 30, and 72% (p?<?0.001) and before 34 weeks in 10, 46, and 84% (p?<?0.001), respectively. Take-home baby rate was 95% after abdominal cerclage, 73% after vaginal cerclage, and 33% after no cerclage. In a third pregnancy, abdominal cerclage (n?=?47), vaginal cerclage (n?=?38), and no cerclage (n?=?8) resulted in pregnancy ending before 34 weeks of gestation in 2, 21, and 25%, respectively (p?=?0.01).

Conclusions

Cervical insufficiency was diagnosed in 24% of women with an initial second trimester spontaneous miscarriage/delivery. In second and third pregnancies, recurrence rates were significantly lower after prophylactic vaginal or abdominal cerclage compared with no cerclage.

     

Spontaneous haemorrhagic stroke complicating severe pre-eclampsia in pregnancy: a case report in a resource-limited setting in Cameroon

Background

Spontaneous intracerebral haemorrhage is a rare complication of preeclampsia during pregnancy associated with a high morbidity and mortality. Compared with the non-pregnant women stroke rates are relatively rare during pregnancy.

Case presentation

We report the case of a 32-year-old female Cameroonian gravida 4 para 3 who presented at 34?weeks of gestation with sudden onset of right sided hemiplegia associated with headache, blurred vision and a blood pressure of 182/126. Cerebral CT scan confirmed a left parietal spontaneous haemorrhage. Emergency caesarean delivery was done and the recovery uneventful.

Conclusion

This case highlights the importance of good neurological examination in pregnant women presenting with neurological symptoms as well as the place of multidisciplinary management in severe life threatening conditions.

     

Ovarian hyperstimulation syndrome following GnRH agonist trigger—think ectopic

Purpose

This study aims to report a case of ovarian hyperstimulation syndrome (OHSS) following GnRH agonist trigger for final follicular maturation.

Methods

This study is a retrospective chart review.

Results

We report the first case of OHSS following GnRH agonist trigger for final follicular maturation and freeze-all, masking extrauterine pregnancy (EUP). The present case report elucidates the feasibility of stimulating and recruiting ovarian follicles yielding mature oocytes during early pregnancy and the ability of GnRH agonist to trigger final follicular maturation during pregnancy, in the presence of high progesterone and hCG levels.

Conclusions

Since OHSS almost always develops after hCG administration or in early pregnancy, its occurrence following GnRH agonist trigger should alert physician to search for either an inadvertent administration of exogenous hCG, or the endogenous secretion of hCG by pregnancy, e.g. EUP, or as part of a paraneoplastic syndrome.

     

Chronic Endometritis and Recurrent Pregnancy Loss

Purpose of Review

Chronic endometritis is generally an asymptomatic condition typically diagnosed by the histopathological presence of plasma cell infiltration in the endometrial stromal compartment. Emerging data suggests that chronic endometritis may be a cause of recurrent pregnancy loss (RPL).

Recent Findings

Chronic endometritis is prevalent in cases of otherwise unexplained recurrent pregnancy loss. Treatment appears to lead to improved pregnancy outcomes in subsequent pregnancies. The use of CD138 immunohistochemistry as a supplement to traditional hematoxylin and eosin staining of plasma cells increases the detection rate of chronic endometritis.

Summary

Chronic endometritis is emerging as a treatable cause of RPL.

     

Male chromosomal polymorphisms reduce cumulative live birth rate for IVF couples

Purpose

Chromosomal polymorphisms are associated with infertility, but their effects on assisted reproductive outcomes are still quite conflicting, especially after IVF treatment. This study evaluated the role of chromosomal polymorphisms of different genders in IVF pregnancy outcomes.

Methods

Four hundred and twenty-five infertile couples undergoing IVF treatment were divided into three groups: 214 couples with normal chromosomes (group A, control group), 86 couples with female polymorphisms (group B), and 125 couples with male polymorphisms (group C). The pregnancy outcomes after the first and cumulative transfer cycles were analyzed, and the main outcome measures were live birth rate (LBR) after the first transfer cycle and cumulative LBR after a complete IVF cycle.

Results

Comparison of pregnancy outcomes after the first transfer cycle within group A, group B, and group C demonstrated a similar LBR as well as other rates of implantation, clinical pregnancy, early miscarriage, and ongoing pregnancy (P > 0.05). However, the analysis of cumulative pregnancy outcomes indicated that compared with group A, group C had a significantly lower LBR per cycle (80.4 vs 68.00%), for a rate ratio of 1.182 (95% CI 1.030 to 1.356, P = 0.01) and a significantly higher cumulative early miscarriage rate (EMR) among clinical pregnancies (7.2 vs 14.7%), for a rate ratio of 0.489 (95% CI 0.248 to 0.963, P = 0.035).

Conclusion

Couples with chromosomal polymorphisms in only male partners have poor pregnancy outcomes after IVF treatment manifesting as high cumulative EMR and low LBR after a complete cycle.

     

Assessment of M2/ANXA5 haplotype as a risk factor in couples with placenta-mediated pregnancy complications

Purpose

The aim of this study was to confirm the associated M2/ANXA5 carrier risk in women with placenta-mediated pregnancy complications (PMPC) and to test their male partners for such association. Further analysis evaluated the influence of maternal vs. paternal M2 alleles on miscarriage.

Methods

Two hundred eighty-eight couples with preeclampsia (PE), intrauterine growth restriction (IUGR), or premature birth (PB) were recruited (n = 96 of each phenotype). The prevalence of the M2 haplotype was compared to two control cohorts. They included a group of women with a history of normal pregnancy without gestational pathology (Munich controls, n = 94) and a random population sample (PopGen controls, n = 533).

Results

Significant association of M2 haplotype and pregnancy complications was confirmed for women and for couples, where prevalence was elevated from 15.4 to 23.8% (p < 0.001). Post hoc analyses demonstrated an association for IUGR and PB individually. A strong link between previous miscarriages and M2 carrier status was identified which may explain the predisposition to placental pregnancy complication. M2/ANXA5 appears to be a risk factor for adverse pregnancy outcomes related, but not limited to miscarriages, with similar prevalence in women and their male partners.

Conclusion

These findings support the proposed physiological function of ANXA5 as an embryonic anticoagulant that appears deficient in contiguous specter of thrombophilia-related pregnancy complications culminating more frequently in miscarriage in a maternal M2 carrier background.

     

The freezing method of cleavage stage embryos has no impact on the weight of the newborns

Purpose

The aim of this study was to study the effect of the embryo freezing method on the birth weight of newborns from frozen embryo transfer (FET) cycles, and the pregnancy results of cleavage stage embryos cryopreserved by slow freezing or vitrification.

Methods

This is a retrospective cohort study undertaken in a University Hospital IVF unit using concurrently both the slow-freezing and the vitrification techniques. All frozen-thawed and vitrified-warmed day 2 and day 3 embryo transfers during the time period from 1 April 2009 to 31 November 2013 were included in the study.

Results

There was no statistically significant weight difference between newborns from vitrified or slow-frozen embryos (3588 vs 3670 g). A higher post-thaw viability rate was achieved after cryopreservation by the vitrification technique compared to the slow-freezing protocol (83.4 vs 61.4 %). The miscarriage rate was lower in the vitrification group (15.7 vs 29.0 %). The live birth rates were similar (19.5 vs 19.1 %) in the slow-freezing and vitrification groups, respectively. Among vitrified embryos, 7.4 embryos needed to be thawed to produce one delivery; in the slow-freezing group, that number was 11.9.

Conclusions

The freezing method has no impact on the weight of the newborn.With lower post-thaw survival rates and higher miscarriage rates, the slow-freezing cryopreservation protocol is inferior to the vitrification technique.

     

Medikamentöse Therapie der Endometriose und Adenomyose

Background

The pharmacological therapy of endometriosis is a cornerstone in the therapy of endometriosis. Not only the right choice of the medication, but also the differentiation between the necessity of medical therapy or surgical intervention is a challenge in the therapy of endometriosis.

Objective

The aim of this article is to demonstrate the different options for medical treatment, thus, providing support in the differentiation between the necessity of medical or surgical treatment.

Material and methods

Various medical treatment options are presented and evaluated with regard to the current literature and guidelines.

Results

Different treatment options are available like oral contraceptives, progestins, and gonadotropin-releasing hormone (GnRH) analogues. The off-label use of aromatase inhibitors is possible in some cases. New treatment options as selective progesterone receptor modulators (SPRM) and oral GnRH antagonists are expected in the future.

Conclusion

There are numerous options for the treatment of endometriosis; however, most are used as off-label therapy. If medical treatment is not successful, surgery is an alternative. In view of the long latency between the first onset of symptoms and the diagnosis of endometriosis and due to the associated severe symptoms, surgery should not be delayed too long if medical treatment is not successful. A reliable diagnosis is only possible by laparoscopy and histological confirmation.