Incomplete Androgen and Progesterone Suppression Following Midluteal GnRHa Prior to Controlled Ovarian Hyperstimulation for IVF-ET

Purpose: We aimed to determine if midluteal GnRH agonist (GnRHa) use prior to controlled ovarian hyperstimulation (COH) results in uniform progesterone and androgen suppression and whether elevations of these hormones occurring early in follicular development may adversely effect the outcome of IVF-ET. Methods: Forty-four COH cycles using midluteal GnRHa were evaluated. Serum gonadotropins (LH and FSH) and gonadal steroids (E ₂ , A, P ₄ , and T) were measured after 10 days of GnRHa administration [cycle day 31 (CD 31)] and again on the day of hCG administration, following COH. Cycle outcomes evaluated were the number of oocytes retrieved, morphologic grade, fertilization, implantation, pregnancy, and spontaneous abortion rates. Results: Endogenous serum FSH was uniformly suppressed (6.32 ± 0.47 IU/L) on CD 31, however, LH was not (23.76 ± 0.76 IU/L). Five and four tenths percent of cycles demonstrated low-level P4 elevations (0.9 ng/ml), 24.4% demonstrated serum androstenedione levels 600 pg/ml, and 39% of cycles were characterized by serum T levels 200 pg/ml despite evidence of E ₂ suppression (30 pg/ml) and the absence of follicular growth by sonography. LH levels were not predictive of incomplete P ₄ or androgen suppression. Elevations of either P ₄ , A, or T occurring early in the follicular phase were not found to correlate with an impairment in clinical cycle outcome. Conclusions: Midluteal GnRHa use prior to COH may result in incomplete suppression of circulating progesterone and androgens. However, these relative elevations, occurring early in the development of the follicular cohort, did not appear to affect IVF cycle outcome adversely.     

卵巢反应性对IVF-ET妊娠结局的影响

目的:探讨IVF-ET促排卵周期中卵巢反应性对妊娠结局的预测能力。方法:回顾性分析402个长方案促排卵周期中所需外源性重组卵泡刺激素总量(rFSH)/成熟卵母细胞数(n)的比值(rFSH/n)与妊娠结局的关系。结果:随着rFSH/n比值升高,基础窦卵泡数(AFC)减少、rFSH总用量增大、获卵数减少、平均胚胎评分下降(P<0.05)。当rFSH/n>450时,临床妊娠率明显下降(P<0.05)。结论:卵巢反应性是影响IVF结局的重要因素,妊娠率随着rFSH/n的增加而下降的截点为rFSH/n>450。     

Computed Tomography Prior to Surgery for Ovarian Carcinoma

The value of investigation of patients with ovarian carcinoma by preoperative computed tomography scan was evaluated in all the patients operated on during the last 2 years; 22 patients were included in this study and evaluated. In 11 patients the scan was performed prior to the primary surgery and in the other 11 patients before second look following chemotherapy. CT scan was found to be highly sensitive in detecting ascites, pelvic wall extension and spread or involvement of the uterus. Peritoneal and omental spread was detected in only half of the patients before primary surgery. Prior to second look operation CT scan was effective in excluding liver metastasis, ascites, paraaortic lymph node enlargement, pelvic wall extension and pelvic residual tumour. Generally, CT scan failed to detect peritoneal and omental spread. It is an important tool for preoperative evaluation of the extension of the disease and planning of surgery, but still, the final staging deserves explorative laparotomy.     

IVF-ET周期中GnRH-a、FSH、hMG配伍方案的比较研究

目的:探讨IVF周期中采用不同促排卵方案时,卵泡液及血清中FSH、LH、E2水平的变化及对胚胎发育、受精、妊娠的影响;单用国产hMG促排卵的效果。方法:120例分成4组。测定卵泡液及取卵日血清中FSH、LH、E2水平,比较四种方案的取卵数、受精率、Ⅰ级、Ⅱ级胚胎形成率和每移植周期妊娠率。结果:四种促排卵方案的卵泡液和血清FSH、E2水平没有差别（P>0.05）,不同垂体降调节者,卵泡液和血清LH水平明显升高（P<0.0001）,四种促排卵方案的取卵数、受精率、优质胚胎形成率、移植周期妊娠率经统计学处理均无显著性差异。结论:卵泡液和血清中LH水平升高可能与应用垂体降调节有关,而与选择纯FSH还是hMG促排卵无关。轻度LH升高并不影响卵泡发育、卵子质量和以后的胚胎发育。IVF周期首选垂体降调节加FSH或FSH/hMG促排卵方案,单用hMG促排卵也可以作为选择。     

Types and Duration of Symptoms Prior to Diagnosis of Invasive or Borderline Ovarian Tumor

OBJECTIVE: The objective was to describe and compare types and duration of symptoms among women with invasive versus borderline ovarian tumors. METHODS: Cases were women, ages 20-69 years, diagnosed with invasive (616) and borderline (151) epithelial ovarian tumors from 1994 to 1998. Symptoms were obtained using a standardized in-person interview. Differences in types and duration of symptoms, time to diagnosis after consulting a physician, and primary reason for diagnosis by invasive/borderline status and histologic type were determined using bivariate and regression analyses controlling for age. RESULTS: Borderline and invasive cases reported similar types of symptoms. However, borderline cases were twice as likely to report not having had symptoms as invasive cases (16 vs 8%, P = 0.005). Prediagnostic symptom duration was longer among borderline versus invasive cases (median: 6 vs 4 months, P < 0.001). The median time from first consultation with a physician to diagnosis (1 month) did not differ by invasive/borderline status. Borderline cases were twice as likely to be diagnosed through routine examination as invasive cases (28 vs 16%, P = 0.001). Invasive cases were more likely to be diagnosed because of symptoms (62 vs 48%, P = 0.002). CONCLUSIONS: Because most (90%) women with ovarian tumors have symptoms and median symptom duration is 4 months, greater awareness of symptoms by women and physicians is needed for the earlier detection of ovarian tumors. The lesser likelihood of being detected by routine examination and the shorter symptom duration for invasive versus borderline cases underscores the need for effective screening and preventive strategies.     

大卵泡穿刺抽吸用于GnRH-a长方案卵泡发育不同步时对IVF-ET结局的影响

目的:探讨GnRH-a长方案周期中出现卵泡发育不同步患者采用大卵泡穿刺抽吸治疗后对体外受精-胚胎移植(IVF-ET)妊娠结局的影响.方法:对64例GnRH-a长方案周期中出现卵泡发育不同步患者的临床资料进行回顾性分析,根据促性腺激素(Gn)启动10日内是否进行大卵泡穿刺抽吸治疗分为穿刺抽吸组(31例)和未穿刺抽吸组(33例),比较两组患者启动Gn4～6天和启动Gn 7—10天卵泡发育不同步情况、促排卵用药情况及妊娠结局,以及未穿刺抽吸组患者取卵时卵泡中有卵子和无卵子(即囊肿)情况及其临床妊娠率的比较.结果:①两组启动Gn 4～6天和启动Gn 7～ 10天时,出现卵泡发育不同步情况比较,差异无统计学意义(P＞0.05).②两组患者GnRH-a剂量、GnRH-a天数、Gn天数、Gn总量、HCG日内膜厚度、HCG日E2/P值、获卵数、获卵率、成熟卵数、成熟卵率、优质胚胎数、临床妊娠率和流产率比较,差异均无统计学意义(P＞0.05).③未穿刺抽吸组患者仅依靠Gn使用的调整,取卵日大卵泡中有卵子与证实为囊肿的患者的临床妊娠率比较,差异无统计学意义(P=1.000).结论:卵泡的不同步发育可以发生在GnRH-a长方案控制性超促排卵的不同时间,出现卵泡发育不同步现象不需要中途进行穿刺抽吸治疗,其与通过调整Gn的使用来调节卵泡的发育而获得的妊娠结局相同.     

卵巢卵黄囊瘤手术和化疗后自然周期体外受精-胚胎移植成功分娩一例并文献复习

卵巢卵黄囊瘤属卵巢恶性生殖细胞肿瘤,占卵巢恶性肿瘤的1%。由于卵巢恶性生殖细胞肿瘤多见于儿童及年轻女性,故保存生育能力是关键。卵巢卵黄囊瘤对化疗药物敏感,手术联合术后辅助化疗是标准治疗方案。对于对侧卵巢和子宫未受肿瘤累及,并且有生育需求的患者均应行保留生育功能的手术。但肿瘤本身、手术和放化疗均可能造成患者不孕,术后可能需要借助辅助生殖技术助孕,本文通过1例卵巢卵黄囊瘤患者手术和术后化疗后行自然周期-体外受精-胚胎移植(NC-IVF-ET)的个案报道和文献复习,探讨卵巢卵黄囊瘤患者的生育助孕策略。     

Continued Chemosensitivity to Cisplatin/Carboplatin in Ovarian Carcinoma Despite Treatment with Multiple Prior Platinum-Based Regimens

While it is well recognized that individuals with ovarian cancer who have previously responded to platinum-based therapy can achieve a second response to cisplatin or carboplatin at the time of relapse, limited data exist in the oncologic literature regarding the number of times this process can be repeated. We briefly report here three patients with ovarian cancer currently being cared for in the Gynecologic Oncology program of the Cleveland Clinic Foundation who have achieved four (1 patient) or five (2 patients) separate clinical responses to cisplatin or carboplatin-based chemotherapy and have survived >4 years since the date of first relapse. This experience emphasizes the point that platinum resistance cannot be defined based on total treatment courses or the number of prior platinum-based regimens delivered, but only by objective evidence of failure of the drugs in an individual patient.     

Successful Spouse Pregnancy of Male Patients with Severe Apalstic Anemia and Chronic Myelogenous Leukemia Using Spermatozoa Banked Prior to Bone Marrow Transplantation and Using the ICSI Procedure: Case Reports

PURPOSE: To report two cases of successful spouse pregnancies which were conceived with long-term cryopreserved spermatozoa that had been collected prior to the male patients receiving a bone marrow transplant. METHODS: The first case is the pregnant wife of a 25-year-old man with chronic myelogenous leukemia, whose semen was collected before bone marrow transplant and then cryopreserved, thawed, and then injected into the wife's eggs via ICSI. The second case is a 28-year-old man with severe aplastic anemia who became a father after his wife's eggs were fertilized via ICSI with thawed spermatozoa. RESULTS: These two cases were achieved pregnancies. CONCLUSIONS: These cases support research that men with malignancy have the chance of fathering their own genetic children. Therefore, it is important to increase the awareness of clinicians, oncologists, and patients to the new developments in preserving fertility for cancer patients.     

A Laparoscopic Adjusted Model Able to Predict the Risk of Intraoperative Capsule Rupture in Early-stage Ovarian Cancer: Laparoscopic Ovarian Cancer Spillage Score (LOChneSS Study)

Study ObjectiveTo identify preoperative/intraoperative patient and tumor characteristics associated with an increased risk of tumor spillage during minimally invasive surgery (MIS) for early-stage ovarian cancer (OC). The secondary end point was to develop a score system able to estimate the risk of tumor rupture during MIS.DesignRetrospective observational study.SettingPatients with International Federation of Gynecology and Obstetrics stage I OC.PatientsPatients aged ≥18 years old, with International Federation of Gynecology and Obstetrics stage IA to IC1 OC of any histology.InterventionsPreoperative and intraoperative characteristics of patients treated with MIS for early-stage OC at Policlinico Universitario Agostino Gemelli, IRCCS in Rome, Italy, from January 1, 2001, to December 31, 2017, were collected.Measurements and Main ResultsA total of 151 patients were included. Previous pelvic surgery was more represented in patients with nonruptured tumors (46.0% vs 63.4%; p = .042). In addition, a larger tumor diameter (p <.001), a higher body mass index (p = .032), ultrasound characteristics (p = .029), and adhesions to large bowel (14% vs 2.0%; p = .003), uterus (44% vs 6.9%; p <.001), contralateral ovary (8.0% vs 0%; p = .004), ovarian fossa (64% vs 14.9%; p <.001), and pouch of Douglas peritoneum (32% vs 4.0%; p <.001) increased rupture rate. At multivariate analysis, a larger tumor diameter (p <.001) and adhesions to ovarian fossa peritoneum (p = .007) were independently associated with intraoperative cancer spillage and included in the score calculation. A disease-free survival (DFS) difference between the rupture group and the no-rupture group was detected (5-year DFS, 74.9% vs 94.4%; p = .011), with superimposable overall survival (5-year overall survival, 91.2% vs 97.9%; p = .089).ConclusionSome preoperative/intraoperative characteristics increase the risk of tumor rupture during MIS for early-stage OC. A laparoscopic predictive model of capsule disruption could be considered to intraoperatively tailor surgical approach to prevent tumor spillage and avoid affecting patient's DFS.     

Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio Might Predict Pediatric Ovarian Torsion: A Single-Institution Experience and Review of the Literature

Study ObjectiveTo determine clinical and laboratory characteristics of ovarian torsion (OT; n = 28) compared with a non-OT control (OC; n = 64) group.DesignRetrospective single-center review performed between January 2006 and December 2016.SettingAcademic department of pediatric surgery.Participants and InterventionsPostoperative diagnosis of pediatric ovarian pathology (International Classification of Diseases, 10th Revision code N83) in 88 patients who underwent 92 surgeries for suspected OT, aged from 3 days to 17.8 years.Main Outcome MeasuresPredictive value for OT according to biometric, procedural, and laboratory parameters at the time of admission.ResultsCompared with OC, OT in patients aged older than 1 year was associated with elevated values regarding white blood cell count, neutrophils, neutrophil to lymphocyte ratio (NLR; all P < .001), platelet to lymphocyte ratio (PLR; P = .003), platelets (P = .011), and a trend toward raised C-reactive protein (P = .054), whereas lymphocytes and lymphocyte to C-reactive protein ratio (both P < .001) were decreased. Using receiver operating characteristic analysis for differentiating OC from OT, besides lymphocytes and NLR (both area under the curve > 0.9), PLR elicited strongest discriminatory accuracy (area under the curve = 0.946 ± 0.037; P < .001; sensitivity 82%; specificity 90%). At binary logistic regression analysis PLR (P = .018) was independently predictive of OT. OT was suspected on ultrasound imaging in 15/18 (83%), showed a right-sided dominance in 13/18 (72%), and was associated with younger age (P = .003). No differences regarding laboratory or procedural parameters in patients aged younger than 1 year were discerned.ConclusionBlood count indices such as PLR, NLR, and lymphocyte to C-reactive protein ratio might be helpful in identification of inflammatory processes as induced by ischemia in OT. Together with ultrasound and clinical features, these parameters constitute potential predictors of OT in girls aged older than 1 year.     

Unilateral Versus Bilateral Laparoscopic Ovarian Drilling Using Thermal Dose Adjusted According to Ovarian Volume in CC-Resistant PCOS,A Randomized Study

Objective

This study aimed to evaluate the efficacy of unilateral laparoscopic ovarian drilling versus bilateral laparoscopic ovarian drilling with thermal dose adjusted according to ovarian volume in clomiphene citrate (CC)-resistant PCOS patients in terms of endocrine changes, menstrual cycle resumption, ovulation and pregnancy rates.

Patients and Methods

This study was conducted in the Department of Obstetrics and Gynecology, Zagazig university hospitals. One hundred CC-resistant PCOS patients were divided into two groups. Group (I) (50 patients) underwent unilateral laparoscopic ovarian drilling with thermal dose adjusted according to ovarian volume (60 J/cm³ of ovarian tissue), and group (II) (50 patients) underwent bilateral laparoscopic ovarian drilling using the same previously mentioned thermal dose. Endocrinal changes and menstrual cycle resumption were assessed within 8 weeks postoperatively, but the ovulation and pregnancy rates were estimated after 6-month follow-up period.

Results

There was no statistically significant difference between the two groups as regards demographic data (p > 0.05). As regards menstruation cycle resumption (62.5 vs. 81%) (p = 0.047), total ovulation rate (54.2 vs. 78.7%) (p = 0.011) and cumulative pregnancy rate (33.3 vs. 55.3%) (p = 0.031), there was statistically significant difference between both groups. After drilling, there were highly statistically significant decrease in the mean serum levels of luteinizing hormone (LH) and significant decrease in the mean serum levels of testosterone in both groups. Mean serum level of follicle stimulating hormone (FSH) did not change significantly in both groups after drilling.

Conclusion

Bilateral laparoscopic ovarian drilling with thermal dose adjusted according to ovarian volume is more effective than the right-sided unilateral technique with thermal dose adjusted according to ovarian volume in terms of menstrual cycle resumption, ovulation and cumulative pregnancy rates in CC-resistant PCOS patients.

     

Using Estimated Fetal Weight From Ultrasonography at 18 to 22 Weeks to Predict Gestational Diabetes Mellitus and Newborn Macrosomia

ObjectivesTo determine if fetal macrosomia in the second trimester predicts the onset of gestational diabetes mellitus (GDM) or large for gestational age (LGA) birth weight.MethodsWe performed a case–control study using data from the Diabetes in Pregnancy Clinic in our tertiary care hospital. Cases were women with GDM requiring insulin (n = 65) or controlled with diet (n = 65). Control subjects were women who screened negative for GDM at 24 to 28 weeks’ gestation (n = 131). Estimated fetal weight (EFW) was determined by ultrasound at 18 to 22 weeks.ResultsEstimated fetal weight that was one standard deviation (70 g) higher at 18 to 22 weeks was not associated with subsequent GDM (adjusted OR [aOR] 1.00, 95% confidence intervals 0.61 to 1.66), but was associated with a 231 g (95% CI 128 g to 334 g) increase in birth weight and increased odds of LGA (aOR 4.02, 95% CI 1.76 to 9.19) after adjusting for gestational age at the time of estimating fetal weight, maternal age, parity, BMI and GDM treatment.ConclusionEFW at 18 to 22 weeks did not predict the onset of GDM, but did predict LGA.     

Diagnosis of Subclinical Amniotic Fluid Infection Prior to Rescue Cerclage Using Gram Stain and Glucose Tests: An Individual Patient Meta-Analysis

ObjectivesMicrobial invasion of the amniotic cavity (MIAC) can affect outcomes following rescue cerclage. We carried out a study to compare the diagnostic performance of the Gram stain and glucose tests for detecting subclinical MIAC.MethodsWe used individual-level data from published studies on Gram stain, glucose, and amniotic fluid culture among women with preterm labour. We calculated the sensitivity, specificity, area under the curve (AUC) and other indices, with amniotic fluid culture results used as the gold standard. The probability of infection using both tests as predictors was also estimated using logistic regression.ResultsThe rate of culture-confirmed MIAC was 11.8% (34 of 288 women). The Gram stain test yielded a sensitivity of 65% (95% CI 46% to 78%) and a specificity of 99% (95% CI 98% to 100%). A positive Gram stain or glucose test had a sensitivity of 88% (95% CI 72% to 96%) and a specificity of 87% (95% CI 82% to 90%), while a positive Gram stain and a positive glucose test had a sensitivity of 62% (95% CI 44% to 77%) and a specificity of 100% (95% CI 98% to 100%). The AUC for the tests were Gram stain 0.82 (95% CI 0.74 to 0.90), glucose 0.86 (95% CI 0.80 to 0.93), and combined Gram stain and glucose 0.92 (95% CI 0.86 to 0.98). Using the tests, singly or in combination, provided greater clinically important calibration, risk-stratification, and classification accuracy than using no tests.ConclusionAmniotic fluid Gram stain and/or glucose testing provides substantially improved performance for the diagnosis of subclinical MIAC compared with no testing.     

Successful Pregnancy After the Vitrification of Zygotes Using Commercial Vitrification Solutions and Conventional Straws to Protect Against Infections in Liquid Nitrogen

Purpose: To report on successful birth after the transfer of postthawed human zygotes that were vitrified using a conventional straw for the purpose of protecting them from infections and a low-toxicity cryoprotectant that is commercially sold.Methods: A primary infertile couple presented at our IVF program. After being checked for fertilization, the embryos were not transferred to the uterus at that cycle. Instead, all of them were cryopreserved at the 2-pronuclei stage using our original vitrification method. After the vitrification and warming of four zygotes, two embryos were transferred into the uterus.Results: Twenty-one 2-pronuclei embryos were vitrified in liquid nitrogen. After 2 embryos were thawed and transferred, successful pregnancy was the outcome, and a healthy boy was born at term.Conclusions: Vitrification is a simple procedure and requires less time than slow freezing. Vitrification of zygotes in a conventional straw seems to be sufficient for viability and works to store the zygotes safely.     

Using Clinical Symptoms to Predict Adverse Maternal and Perinatal Outcomes in Women With Preeclampsia: Data From the PIERS (Pre-eclampsia Integrated Estimate of RiSk) Study

ObjectivesPreeclampsia is a leading cause of maternal morbidity. The clinical challenge lies in predicting which women with preeclampsia will suffer adverse outcomes and would benefit from treatment, while minimizing potentially harmful interventions Our aim was to determine the ability of maternal symptoms (i.e., severe nausea or vomiting, headache, visual disturbance, right upper quadrant pain or epigastric pain, abdominal pain or vaginal bleeding, and chest pain or dyspnea) to predict adverse maternal or perinatal outcomes.MethodsWe used data from the PIERS (Pre-eclampsia Integrated Estimate of RiSk) study, a multicentre, prospective cohort study designed to investigate the maternal risks associated with preeclampsia Relative risks and receiver operating characteristic (ROC) curves were assessed for each preeclampsia symptom and outcome pair.ResultsOf 2023 women who underwent assessment, 52% experienced at least one preeclampsia symptom, with 5.2% and 5.3% respectively experiencing an adverse maternal or perinatal outcome. No symptom and outcome pair, in either of the maternal or perinatal groups, achieved an area under the ROC curve value > 0.7, which would be necessary to demonstrate a discriminatory predictive value.ConclusionMaternal symptoms of preeclampsia are not independently valid predictors of maternal adverse outcome Caution should be used when making clinical decisions on the basis of symptoms alone in the preeclamptic patient.