Trichosanthin, a Chinese medicine for the medical treatment of ectopic pregnancy with high levels of β-hCG

This was a retrospective study of the effectiveness of trichosanthin (TCS), an active component isolated from the Chinese herb root tuber of Trichosanthes kirilowii on 140 cases of ectopic pregnancy with higher levels of β-human chorionic gonadotropin (β-hCG) managed with a single dose of TCS treatment. Trichosanthin has been used for medical treatment of ectopic pregnancy in China since the 1980s. This study was performed in a major teaching hospitals in China. The mean pretreatment level of β-hCG in the TCS treatment group was 3387.57 IU/L. The success rate of TCS treatment was 85% (119 of 140) which was similar to methotrexate (MTX) treatment. In 86 women with a high level of β-hCG (over 2000 IU/L), the success rate was 80.08% when treated with TCS. Of this group, 26 women who had a high level of β-hCG (over 5000 IU/L) showed a success rate of 73%. The level of β-hCG on days 4, 7, and 10 in TCS group was significantly decreased. This study has shown that TCS may be an option for the medical treatment of unruptured ectopic pregnancy or an option for the treatment of ectopic pregnancy with higher levels of β-hCG than currently recommended for medical management with MTX.     

Conservative treatment of ectopic pregnancy with methotrexate in a nonoperable patient with Crohn’s disease

We present a case of conservative management using methotrexate for ectopic pregnancy in a nonoperable patient with complicated severe Crohns disease. This case demonstrates the successful use of methotrexate in an unusual situation in which laparoscopy or laparotomy could have further jeopardised the patients medical status.     

Comparison of alternative βhCG follow-up protocols after single-dose methotrexate therapy for tubal ectopic pregnancy

Purpose

To evaluate the performances of five different βhCG follow-up protocols after single-dose methotrexate therapy for tubal ectopic pregnancy (EP).

Methods

Data of patients who received single-dose methotrexate therapy for tubal EP at a university hospital between January 2011 and July 2016 were reviewed. A ‘successful methotrexate treatment’ was defined if the EP treated with no need for surgery. The performances of different protocols were tested by comparing with the currently used ‘15% βhCG decrease between days 4 and 7’ protocol. The tested follow-up protocols were ‘20, 25%, and any βhCG decrease between days 0/1 and 7’ and ‘20% and any βhCG decrease between days 0/1 and 4’.

Results

Among the 96 patients evaluated, 12 (12.5%) required second dose. Totally, 91 (94.8%) patients treated successfully with no need for surgery. Four patients were operated within 4 days following the second dose. One patient who did not need second dose according to the standard follow-up protocol was operated on the 10th day due to rupture (specificity = 80%). Two protocols, namely ‘20% βhCG decrease between days 0/1 and 7’ and ‘any βhCG decrease between days 0/1 and 7’ did not show statistically significant differences from the index protocol regarding the number of patients who should be assigned to 2nd dose.

Conclusions

‘Any βhCG decrease between days 0/1 and 7’ protocol may substitute the currently used one to decide second dose methotrexate in tubal EP management. Omitting 4th day measurement seems to be more convenient and cost effective.

     

Increment in β-hCG in the 48-h period prior to treatment: a new variable predictive of therapeutic success in the treatment of ectopic pregnancy with methotrexate

Objectives To evaluate the efficacy of oral progestogen, chlormadinone acetate, and intramuscular (IM) progesterone for luteal support in patients, undergoing assisted reproductive technology (ART) treatment, who were treated with a gonadotropin-releasing hormone agonist (GnRHa). Methods This was a prospective randomized study of 40 patients with normal and high response (serum estradiol > 2,000 pg/ml) in GnRHa down-regulation. Patients were randomized to receive either oral chlormadinone acetate or IM progesterone. The outcomes of ART treatment, including pregnancy and embryo implantation rates, were analyzed. Results There were no significant differences in the clinical pregnancy rates (25 vs. 20%) and in the implantation rates (12.7 vs. 9.1%) of patients who received IM progesterone and oral chlormadinone acetate. Endometrial thickness was also comparable between oral chlormadinone acetate and IM progesterone. Conclusion Oral progestogen, chlormadinone acetate showed a comparable pregnancy rate and live birth rate with IM progesterone as luteal support for the high responders. The optimal methods for luteal support may be dependent on responses to stimulation with gonadotropin, although it is not concluded that oral chlormadinone acetate is recommended as an option for luteal support in high responders.     

ß-hCG and prediction of therapeutic success in ectopic pregnancies treated with methotrexate,results from a prospective observational study

Objective: To evaluate the diagnostic accuracy of different beta-human chorionic gonadotrophin (ß-hCG) levels measurement, for predicting success of medical treatment in cases diagnosed as tubal ectopic pregnancy (TEP).

Design: Five-year prospective observational study.

Setting: Prenatal Diagnosis Unit, Vall d'Hebron University Hospital – Barcelona.

Patients: TEP cases fulfilling criteria for medical treatment with Methotrexate.

Interventions: ß-hCG levels were measured on d 0, 4 and 7 of treatment. Results were compared by non-parametrical tests. A ROC curve was plotted to define cut-off points. Diagnostic accuracy of the different measurements was evaluated.

Main outcome measure: Failure of treatment defined as need for surgical treatment or persistence of high ß-HCG levels despite treatment.

Results: 126 women were diagnosed as TEP, eligible for medical treatment. There were no differences in parity, age, previous TEP, or adnexal mass size. Success rate was 88%. ß-HCG decreased significantly more, between days 0–7 and 4–7, in the successful cases. LR for success prediction was 6.2 and 7.8 for ß-HCG levels at days 4 and 7 respectively, 4.02 and 2.47 for decrement between days 0–7 (25%) and 4–7 (20%), respectively.

Conclusion: ß-hCG cutoff values have a potential for predicting a successful medical treatment of TEP.     

Surgical treatment of ectopic pregnancy by single port access with SILS® system: preliminary study

Aim

To evaluate feasibility of surgical treatment for ectopic pregnancy with single laparoscopic access with SILS^® system.

Patients and methods

We conducted an open study from 1/7/2009 to 1/12/2010 in a single gynaecologic department. All procedures were performed by three operators. Procedures evaluated were corneal resection, salpingotomy, salpingectomy. Feasibility, per- and postoperative data were reported.

Results

We performed completely 31 over 32 (97%) surgical procedures with SILS^® system (27 salpingectomies and five salpingotomies). In one case, conversion to conventional laparoscopy was required. No intra- or postoperative complications were reported.

Conclusion

Laparoscopic surgery for ectopic pregnancy by single access seems feasible with SILS^® system. Further study including larger number of patients and operators were necessary to confirm risks and advantages of this technique.     

Do serum beta-human chorionic gonadotropin levels on day 4 following methotrexate treatment of patients with ectopic pregnancy predict successful single-dose therapy?

The purpose of this study is to assess whether serum beta-human chorionic gonadotropin (beta-hCG) levels on day 4 following methotrexate (MTX) treatment in patients with ectopic pregnancy predict successful single-dose therapy or the need for subsequent surgical intervention. Retrospective analysis of patients with ectopic pregnancies treated with MTX (50 mg/m (2)) was conducted. Inclusion criteria for MTX management were serum beta-hCG < 15,000 mU/mL, absent fetal cardiac activity, ultrasonographic gestational sac < 3.5 cm, normal liver function tests, hemodynamically stable patient with no evidence of hemoperitoneum, and informed consent. Day 1, 4, and 7 serum beta-hCG levels were obtained. Outcome parameters included successful single-dose MTX management, the requirement for multiple treatments, and whether subsequent surgery was required. Receiver operator characteristic (ROC) curves were used. P < 0.05 was considered significant throughout. Eighty-three patients were studied. Of these, 60 patients were treated successfully with single doses, 16 patients required two doses, and two patients required three doses of MTX, and five underwent surgical management. Mean day 1 serum beta-hCG levels of patients successfully treated with single-dose MTX was 3938.5 (+/- 589.2 [standard deviation]) versus 1767.65 (+/- 1237.8) mU/mL in patients requiring multiple doses of MTX therapy, ( P < 0.0001). ROC curves for serum beta-hCG levels on days 1, 4, and 7 were 0.449, 0.592, and 0.754, respectively, indicating that only day 7 serum beta-hCG levels were associated with successful single-dose MTX therapy. Serum beta-hCG levels on day 4 of MTX in patients with ectopic pregnancy do not predict successful single-dose therapy or the need for surgery.     

Decline in βhCG levels between days 0 and 4 after a single dose of methotrexate for ectopic pregnancy predicts treatment success: a retrospective cohort study

In current protocols for the medical management of ectopic pregnancies, the first indication of treatment response is obtained no sooner than day 7. We examined whether human chorionic gonadotrophin (βhCG) trends between days 0 and 4 after methotrexate provide an earlier indication of the likely outcome. Of 33 patients where serum βhCG dropped between days 0 and 4 after methotrexate, the ectopic pregnancy was resolved in 88% of cases without further treatment. Of 12 women where serum βhCG rose between days 0 and 4, only 42% had treatment success. A fall in βhCG between days 0 and 4 after treatment with methotrexate for ectopic pregnancy predicts a high likelihood of treatment success.     

Expression of human β-defensin-2 in the eutopic and ectopic endometrial tissues in patients with endometriosis

Objective

To investigate the expression of human β-defensin-2 (hBD-2) in the endometrium of patients with endometriosis (EMS) and explore the potential role of hBD-2 in the pathogenesis of EMS.

Design

Prospective controlled study.

Sample

50 women including EMS patients undergoing laparoscopic ovarian cystectomy and non-EMS patients undergoing hysterectomy for uterine fibroids.

Setting

Large university teaching hospital.

Methods

Patients were divided into EMS and non-EMS groups. The gene expressions of hBD-2, interleukin (IL)-1β and tumor necrosis factor (TNF)-α in the endometrial tissues of each group were detected with real-time quantitative polymerase chain reaction (PCR), and hBD-2 protein expression with immunohistochemical method.

Results

The gene expression levels of hBD-2, TNF-α, and IL-1β as well as the positive expression rate of hBD-2 protein in the ectopic endometrium of EMS patients were significantly higher than those in the eutopic endometrium of EMS and non-EMS patients (all P < 0.05). Correlation analysis showed that the gene expression levels of hBD-2 in the ectopic and eutopic endometrium of EMS patients were positively correlated with the gene expression levels of IL-1β and TNF-α (P < 0.01).

Conclusion

High levels of hBD-2 gene and protein expressions in the ectopic endometrium of EMS patients may be an important contributor in the pathogenesis of EMS. TNF-α and IL-1β may promote the upregulation of hBD-2 expression.     

Assessment of β-human chorionic gonadotropin level as a reliable predictor of tubal patency confirmed with transvaginal ultrasound-guided selective salpingography (TVSSG) following conservative treatment of tubal pregnancy

Objective  

To try putting the β-hCG level as a reliable predictor for tubal patency for women, who had previously undergone expectant treatment or who had received systemic methotrexate injection because of tubal pregnancy, and to simply check their tubal patency using a newly proposed procedure, a transvaginal ultrasound guided selective salpingography (TVSSG).     

Lower placental growth factor and higher free β-hCG and PAPP-A levels in the fetal circulation of near-term pregnancies complicated with severe preeclampsia

Background: An imbalance between anti- and angiogenic factors during early placentation is key for the development of preeclampsia. Nevertheless, the majority of studies addressing this issue relate to maternal blood and not the fetal circulation.

Objective: To measure placental growth factor (PlGF), free beta human chorionic gonadotropin (β-hCG), and pregnancy-associated plasma protein-A (PAPP-A) levels in the fetal circulation of near-term pregnancies complicated with severe preeclampsia (n?=?20), and their controls matched for parity, and maternal and gestational age.

Method: Upon delivery, a blood sample was withdrawn from the umbilical artery and vein of each case and its control in order to measure the proposed analytes using direct fluoroimmunoassay.

Results: Preeclampsia cases showed significantly lower median PlGF levels in fetal circulation as compared to controls (25.2 versus 36.9 and 23.6 versus 33.9?pg/mL, artery and vein, respectively, p?0.05). Contrarily, cases displayed higher concentrations of PAPP-A (1024.0 versus 720.9 [median] and 1027.0?±?298.4 versus 690.3?±?401.9 mIU/L, artery and vein, respectively, p?<?0.05), and free β-hCG (mean: 33.9?±?4.3 versus 17.2?±?4.0 and 30.1?±?5.2 versus 13.7?±?3.3?ng/mL, artery, and vein respectively, p?<?0.05).

Conclusion: Lower PlGF and higher PAPP-A and free β-hCG levels were found in the fetal circulation of near-term severe preeclamptic pregnancies. There is a need for more research in this regard.     

Projecting the potential impact of the Cap-Score™ on clinical pregnancy,live births,and medical costs in couples with unexplained infertility

Purpose

The Cap-Score? was developed to assess the capacitation status of men, thereby enabling personalized management of unexplained infertility by choosing timed intrauterine insemination (IUI), versus immediate in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in individuals with a low Cap-Score?. The objective of this study was to estimate the differences in outcomes and costs comparing the use of the Cap-Score? with timed IUI (CS-TI) and the standard of care (SOC), which was assumed to be three IUI cycles followed by three IVF-ICSI cycles.

Methods

We developed and parameterized a decision-analytic model of management of unexplained infertility for women based on data from the published literature. We calculated the clinical pregnancy rates, live birth rates, and medical costs comparing CS-TI and SOC. We used Monte Carlo simulation to quantify uncertainty in projected estimates and performed univariate sensitivity analysis.

Results

Compared to SOC, CS-TI was projected to increase the pregnancy rate by 1–26%, marginally reduce live birth rates by 1–3% in couples with women below 40 years, increase live birth rates by 3–7% in couples with women over 40 years, reduce mean medical costs by $4000–$19,200, reduce IUI costs by $600–$1370, and reduce IVF costs by $3400–$17,800, depending on the woman’s age.

Conclusion

The Cap-Score? is a potentially valuable clinical tool for management of unexplained infertility because it is projected to improve clinical pregnancy rates, save money, and, depending on the price of the test, increase access to treatment for infertility.