Successful pregnancy after missing HCG injection in in vitro fertilization and embryo transfer

We reported a rare case of successful pregnancy and delivery of healthy twins after salvage injection of the human chorionic gonadotropin (HCG) for empty follicular syndrome because of missing scheduled HCG injection in the in vitro fertilization and embryo transfer cycle.

A quantification of human cells using an ERV-3 real time PCR assay

A novel approach to quantifying human cells using a real time PCR assay was developed. The target sequence used in the assay is a 135 bp segment within the unique 1.7 kb Hind III / Pst I fragment of the ERV-3 envelope gene. ERV-3 is a full-length human endogenous retrovirus present in known copy number in all human cells. The detection range of ERV-3 by real time PCR is from 10(6) to 10(1). The precision described, sensitivity and specificity of the assay indicate that the ERV-3 sequence is an accurate cell quantitation marker. The quantitative ERV-3 assay enables simple, fast, and reproducible detection and quantitation of the cell number. The assay can be used to determine the sample DNA conditions and also it can be used to adjust the quantitative DNA measurements of other target gene assays relative to the number of cell equivalents.

Laparoscopic bipolar coagulation of uterine vessels: a new method for treating symptomatic fibroids

OBJECTIVE

To evaluate the effects of laparoscopic bipolar coagulation of uterine vessels in treating symptomatic fibroids.

DESIGN

Prospective clinical study.

SETTING

University-affiliated tertiary referral center.

PATIENT(S)

Eighty-seven women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri.

INTERVENTION(S)

Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries.

MAIN OUTCOME MEASURE(S)

Percentage reduction in the dominant fibroid size and clinical response evaluation.

RESULT(S)

Eighty-five (97.7%) of 87 patients underwent technically successful laparoscopic coagulation of uterine vessels without intraoperative complications. The mean follow-up time was 10.2 months. Symptomatic improvement was reported in 76 (89.4%) of 85 patients, including 18 (21.2%) with complete resolution of symptoms. Significant reductions in the dominant fibroid size (average, 76%) and the uterine volume (average, 46%) were sonographically demonstrated. Two patients conceived 4 and 9 months, respectively, after treatment. Three (3.5%) premenopausal women became postmenopausal postoperatively.

CONCLUSION(S)

Laparoscopic bipolar coagulation of uterine vessels appears to be a promising new method for treating fibroid-related menorrhagia and pelvic pain.

Major complications of operative and diagnostic laparoscopy for gynecologic disease

STUDY OBJECTIVE

To compare complication rates of diagnostic and operative laparoscopy. Design. Retrospective study (Canadian Task Force classification II-2).

SETTING

One medical center and three teaching hospitals.

PATIENTS

Six thousand four hundred fifty-one women with various indications for laparoscopic diagnosis and/or laparoscopic surgery from January 1994 through June 1999.

INTERVENTION

Diagnostic and operative laparoscopies.

MEASUREMENTS AND MAIN RESULTS

Forty-two major complications occurred that directly resulted in one death. One patient had stomach injury, 3 had major vessel injuries, 5 had ureter injuries, 10 had intestinal injuries, and 23 had bladder injuries. The overall complication rate for all laparoscopies was 0.65% (42/6451); however, it rose to 0.80% (39/4865) for operative laparoscopy compared with 0.19% for diagnostic laparoscopy (3/1586; p <0.001, Fisher's exact test).

CONCLUSION

Laparoscopic surgery is appropriate for managing various gynecologic diseases and has an acceptable complication rate. However, operative laparoscopy should be performed carefully because its rate of complications is significantly higher than that of diagnostic laparoscopy, especially for laparoscopic-assisted vaginal hysterectomy. (J Am Assoc Gynecol Laparosc 8(1):68-73, 2001)

Excision of mature teratoma using culdotomy, with and without laparoscopy: a prospective randomised trial

OBJECTIVE

To compare the results of removing mature teratoma with laparoscopy or without laparoscopy.

DESIGN

A prospective, randomised trial.

SETTING

Medical centre.

PARTICIPANTS

Seventy-nine women with mature teratomas identified using results of ultrasound examinations and biochemical markers.

INTERVENTION

Cystectomy with laparoscopic approach or without laparoscopic approach through a culdotomy.

METHODS

Patients were randomly assigned to have their cysts removed via vaginal cystectomy without laparoscopy (n = 37, Group A) or laparoscopic cystectomy via culdotomy opening (n = 42, Group B). Inclusion criteria were history of vaginal delivery, no previous abdominal surgery, no history of pelvic inflammatory disease, no medical illness, and no presenting symptoms. Eight women randomised to Group A withdrew before surgery. The laparoscopically resected tumours were each put into a cellulose bag, and tumours without laparoscopic-assistance were removed directly via the vagina.

RESULTS

Blood loss in Group A (88 +/- 37 ml) was significantly more than that in Group B (64 +/- 20 ml, P = 0.000). The post-operative recovery times were 20 and 17 hours, respectively (P = 0.030). The rates of successful surgery were 58.6 and 97.6%, respectively (P = 0.002). The spillage rates were 44.8% and 19.0%, respectively (P = 0.006). There were no significant differences in tumour size, patient age, and operative time between groups.

CONCLUSION

Cystectomy without assistance of laparoscopy could be applied to manage mature teratoma of the ovary; however, because of the difficulty of this technique, we had high percentages of tumour spillage and more blood loss during operation and a high percentage of patients who required conversion to laparotomy compared with laparoscopic cystectomy. We favoured laparoscopically assisted cystectomy to manage mature teratoma.

Intraperitoneal cisplatin-based chemotherapy vs. intravenous cisplatin-based chemotherapy for stage III optimally cytoreduced epithelial ovarian cancer

OBJECTIVE

To compare the survival between intraperitoneal cisplatin-based chemotherapy (IPCT) and intravenous cisplatin-based chemotherapy (IVCT) in stage III epithelial ovarian cancer with minimal residual disease (<1 cm) after primary debulking surgery.

METHOD

One hundred and thirty-two patients with stage III epithelial ovarian cancer after optimal primary debulking surgery with minimal residual disease between April 1990 and March 1995 were entered into a randomized clinical trial in which IPCT or IVCT was administered at 3-week intervals. Patients in the IPCT arm received cisplatin-based (100 mg/m(2)) intraperitoneal chemotherapy. Patients in the IVCT arm received cisplatin-based (50 mg/m(2)) intravenous chemotherapy. The tumor response was assessed every 3 months. The hematological toxicity using the South West Oncology Group (SWOG) toxicity criteria was assessed. Catheter complications associated with intraperitoneal chemotherapy were also analyzed.

RESULT

The estimated median survival in the IPCT group was 43 months (95% confidence interval, 34-54) and IVCT group was 48 months (95% confidence interval, 37-59). The hazard ratio of death was not statistically significant between IPCT and IVCT (hazard ratio, 1.13; 95% CI, 0.69-1.86; P=0.317). The frequencies of hematological toxic effects were significantly lower in the IPCT group than in the IVCT group.

CONCLUSION

Intravenous and intraperitoneal chemotherapy are associated with equivalent survival in patients with minimal residual stage III epithelial ovarian cancer after optimal cytoreductive surgery.

Power Doppler angiographic appearance and blood flow velocity waveforms in invasive cervical carcinoma

OBJECTIVES

The aim of this study was to investigate the effectiveness of transvaginal power Doppler angiography in predicting cervical malignancy by detecting intratumoral blood flow and to understand the relationship between squamous cell carcinoma (SCC) serum levels and intratumoral blood flow analysis of invasive cervical carcinoma before treatment.

METHODS

Thirty-eight patients with cervical carcinoma (35 with stages Ia to IVb invasive carcinoma, 3 with cervical carcinoma in situ) were enrolled for the evaluation of tumor flow using transvaginal ultrasound accompanied with power Doppler angiography before surgery. The pulsatility, resistance index, and vascular index of tumor flow were measured. Thirty patients with proven healthy cervices were used as the control group. Pretreatment SCC serum levels were obtained in 34 women with cervical carcinoma.

RESULTS

The pulsatility index and resistance index were significantly lower in the study group than in the control group (P < 0.0001). The vascular index was also significantly lower in the study group than in the control group (P < 0.0001). There were no significant differences among patients with SCC type and non-SCC type cervical carcinoma (P > 0.05) among the six parameters. There was no significant correlation between the pretreatment SCC serum levels with any of the six parameters obtained from the intratumoral blood flow analysis in the SCC group.

CONCLUSIONS

Transvaginal ultrasound with power Doppler angiography is a valuable diagnostic tool for differentiating benign tumors of the cervix from malignant ones. Intratumoral blood flow of the cervix supplied us with practical diagnostic information before surgery and may aid in early prediction and management of cervical carcinoma. The use of transvaginal ultrasound with power Doppler angiography in the grading of vascularity ratio within cervical masses provided more sonographic characteristics among the different subclassifications of cervical cancer and is more useful than color Doppler imaging in the visualization of sonographic morphology.

Brain-damaged survivors after intrauterine death of a monochorionic twin

BACKGROUND

Potential risks for a surviving twin after fetal death of a co-twin in twin-to-twin transfusion syndrome (TTTS) has been documented. Although some studies suggest ending a twin pregnancy after a single fetal death as soon as possible in order to minimize the risks of thromboembolic complications in the surviving twin, we are more concerned about the risks of a premature birth. In this study, we searched for a potential marker to predict thromboembolic complications in the surviving twin.

METHODS

From 1993 to 1998, nine women in two teaching hospitals had pregnancies complicated by TTTS and the death of one fetus. In addition to routine ultrasound examinations and obstetric monitoring, all patients had disseminated intravascular coagulation tests. The outcome of the surviving fetus was recorded.

RESULTS

Three patients had silent and minimal coagulopathy (33%) that revealed only the presence of D-dimer. Among these three patients, two had a disappearance of serum D-dimer, but the other one had persistent D-dimer levels for more than 5 weeks and delivered a fetus with a cerebral infarction. Except for the above-mentioned fetus, all surviving fetuses were normal and healthy and were delivered at the median gestational age of 33 (range, 31-36) weeks. Of the nine surviving children, the mean interval between fetal death of one twin and delivery of the healthy twin was 22.7 days, ranging from 3 days to 47 days.

CONCLUSIONS

All patients having TTTS associated with one fetal death should be carefully monitored for coagulopathy; the appropriate time for delivery might depend on the duration of persistent D-dimer in the maternal blood. The long-term presence of D-dimer in the maternal serum may indicate a severe underlying thromboembolic complication in the surviving twin after intrauterine death of a monochorionic twin. Due to the increased risks of morbidity in premature births, the benefit of early termination of pregnancy in order to protect against subsequent sequelae in the surviving twin is minor and remains an area for future research.

BRCA1 mutations in Taiwanese with epithelial ovarian carcinoma and sporadic primary serous peritoneal carcinoma

BACKGROUND

Germline BRCA1 mutations of sporadic ovarian cancers are presumed to be rare events, except among specific populations. To date, the status of germline BRCA1 mutations in Taiwanese with primary epithelial ovarian carcinoma (PEOC) is still unknown. In this study, we tried to answer part of this question.

METHODS

Sixty-four patients documented with PEOC, four patients with family history of breast and/or ovary cancer syndrome and five patients with sporadic primary serous peritoneal carcinoma (PSPC) were enrolled in this retrospective study from January 1994 through June 1999. At the same time, 50 normal healthy Taiwanese without family history were enrolled in this study. Germline DNA from these patients was screened for mutations in the BRCA1 gene using polymerase chain reaction-based single-stranded conformation polymorphism analysis (PCR-SSCP). Shifting DNA bands were sequenced.

RESULTS

One of the 64 patients with PEOC (1.6%) exhibited germline BRCA1 heterozygous mutation which was exon11 single-base substitution at nucleotide1047 (CAG to TAG). One of the five patients with PSPC (20%) exhibited an exon11 single-base substitution at nucleotide 914 (TCT to TCC) with resultant silent mutation. One of the normal healthy Taiwanese (2%) was found to have an exon 2 single-base substitution at nucleotide 152 (A-->C) which was also a silent mutation. No mutations of BRCA1 were detected in four patients with a family history of breast and/or ovarian cancer.

CONCLUSIONS

Based on this study, it was very difficult to obtain precise data to prove the value of applying genetic testing of BRCA1 mutations in Taiwanese patients with sporadic epithelial ovarian cancers or sporadic PSPC and even with a family history of breast and/or ovarian cancer because of its rare event and because of the too small number of cases available in this study.

Isolated tubal torsion managed laparoscopically

Adnexal cystic lesions in women of reproductive age are common. Most are functional ovarian cysts, followed by paraovarian cysts, hydrosalpinx, and adnexal torsion. A 34-year-old woman experienced mild abdominal pain, nausea, and low-grade fever. She received empiric antibiotics in an outpatient clinic after a diagnosis of tubo-ovarian abscess. After 3 days she was referred to our hospital with no improvement in symptoms or signs. Isolated fallopian tube torsion was diagnosed and successfully treated by laparoscopy. Laparoscopy played an important role in making an accurate diagnosis and avoiding unnecessary delays in treatment.

Prenatal diagnosis and management of congenital cystic adenomatoid malformation

Congenital cystic adenomatoid malformation (CCAM) is a rare pulmonary malformation resulting from excessive overgrowth of the terminal bronchioles. We present two CCAM case studies: type I (macrocystic) and type III (microcystic), diagnosed by antenatal ultrasonography at 31 and 21 weeks' gestation, respectively. In the former, multiple dilated cystic masses in the fetal left lung, with polyhydramnios, were identified during the antepartum examination. A postnatal thoracotomy with lobectomy was performed due to persistent cyanosis and resulted in a good outcome. In the latter case, an echogenic mass with multiple cysts in the fetal right lung was detected by prenatal sonography. The parents decided to terminate the pregnancy after prenatal counseling.

Dilemma in managing spontaneous pneumoperitoneum: a case report

Pneumoperitoneum is often associated with an underlying severe life-threatening emergency. This emergency is always treated successfully by a surgical approach. When a patient situated in hopeless situation but is found with spontaneous pneumoperitoneum, it creates a dilemma. We deal with such a rare situation which occurred in a 58-year-old woman with recurrent cervical carcinoma. The patient received a radical hysterectomy, pelvic lymph node dissection and bilateral salpingo-oophorectomy 10 years ago. Recurrent retroperitoneal lymphadenopathy and inguinal lymphadenopathy were suspected by computed tomography and proven by excision biopsy of inguinal lymph node. She received a complete course of concurrent chemoradiation therapy; however, clinically persistent disease was suspected although it was very difficult to prove. Unfortunately, the case was complicated by severe radiation fibrosis over the whole abdominal wall, poor appetite and urinary tract infection. She was treated with supportive care treatment. Nevertheless, the patient was attacked by spontaneous pneumoperitoneum during hospitalization and died later and autopsy of the patient showed military carcinomatosis of the abdominal cavity and lower abdominal wall without any evidence of internal hollow organ perforation and intraabdominal infection. The cause of death might be related to her carcinomatosis with severe chacexia. Because pneumoperitoneum is always considered as a surgical emergency, we reviewed the possible causes of non-surgical pneumoperitoneum to avoid an unnecessary surgical approach.

Posterior uterine wall rupture during labour

Vaginal births after Caesarean section (VBAC) are well-accepted procedures when pregnant women do not have any contra-indications. The possibilities of the uterine dehisence and rupture during VBAC should always be considered. This occurrence is usually related to the previous scar tissue and subsequent risk is acceptable. Nevertheless, rupture that occurs in presumably normal tissue areas of the uterus instead of in scar tissue areas with resultant perinatal death is extremely rare. We present a 31 year old woman who had posterior uterine rupture when she tried VBAC at 38 weeks gestation. During the course of VBAC, she had a smooth labour course without use of any augmentation medication, but her condition was complicated with uterine rupture without any premonitory signal. It resulted in maternal shock and sequentially the death of the newborn 7 days after delivery. By reviewing this case report, we should keep in mind that prompt response to every woman during labour is of paramount importance to avoid repeating the occurrence of uterine rupture, partly because uterine rupture could occur without prominent signals and partly because subsequent dangers seem to be those created by acts of omission. Finally, the benefits and safety of VBAC have not been undermined because this patient is an isolated and extremely rare case.

Vaginal obliteration after total body irradiation and chemotherapy as treatment for acute myeloid leukemia

Although radiotherapy is an integral part in the management of certain types of hematological malignancies, its effect on the reproductive system has been well documented. We report a rare complication where a patient had complete vaginal obliteration after receiving a dose of total body irradiation (1575 cGy) as part of her treatment for acute myeloid leukemia. A 37-year-old married woman, G3P2, underwent high-dose cyclophosphamide accompanied by high dose (1575 cGy) total body irradiation (TBI) as part of her treatment for acute myeloid leukemia (AML: m1) when she was 35 years of age. After TBI, the patient developed ovarian failure and amenorrhea, which was confirmed by hormonal evaluation. Nevertheless, she did not receive any hormonal replacement therapy and stopped her sexual life for two years. Fortunately, no recurrence of AML was noted. The patient visited our clinic due to difficulty in performing coitus. Physical examination showed a 2-cm short and blinded vaginal pouch. She initially received hormonal replacement therapy followed by surgical correction via vaginoplasty and two months of dilatory replacement and frequent coitus with satisfactory result. To our limited knowledge, vaginal obliteration as a complication of condition regimen has never been reported before. In the present case report, it is unclear whether spontaneous vaginal obliteration resulted from chemotherapy, total body irradiation, or another unknown cause such as a concomitant leukemic infiltration of the vaginal wall, severe bacterial and fungal infection before treatment, or from any combination of the above. However, due to this case presentation, we suggest that such patients must receive hormonal replacement therapy and be encouraged to have a normal sexual life to avoid this possible problem.

Review of trophoblastic disease at Taipei Veterans General Hospital

BACKGROUND

Trophoblastic diseases are well known and encountered frequently within most oriental populations except the Japanese. In recent decades, fewer cases have been reported in Taiwan. The purpose of this study was to review and discuss all patients diagnosed with trophoblastic disease at one particular Taiwanese medical center.

METHODS

Sixty-four patients with malignant gestational trophoblastic disease (GTD) were treated at the Taipei Veterans General Hospital from 1977 to 1995. All cases, except those of placental-site trophoblastic disease, were included in this study.

RESULTS

Of the 64 cases of GTD identified, 36 were nonmetastatic and 28 were metastatic. The common metastatic sites were the lungs, followed by the brain and/or liver. Six patients died of the disease. The majority of these patients (5/6) suffered from liver and/or brain metastases.

CONCLUSIONS

GTD was found to be a highly chemosensitive and curable disease. However, a significant proportion of patients die of the disease. More effective therapeutic protocols may be required in such patients to improve the survival rate.

Whole-body PET with (fluorine-18)-2-deoxyglucose for detecting recurrent primary serous peritoneal carcinoma: An initial report

OBJECTIVE

Because of the limited sensitivity and specificity of conventional tools such as computerized tomography (CT) or magnetic resonance imaging (MRI) for detecting persistent or recurrent primary serous peritoneal carcinoma (PSPC), a reliable means of diagnosis remains elusive. Positron emission tomography (PET) scanning may offer another approach to this problem.

METHODS

A prospective study of three patients requiring surgical exploration for suspected recurrence of PSPC received a whole-body PET (fluorine-18)-2-deoxyglucose (FDG) scanning in a teaching hospital from July 1995 to December 1998. The suspected recurrence was based upon clinical findings including a detailed physical examination, serum CA-125 marker ultrasound, CT, and MRI. Three patients were enrolled in this study.

RESULTS

In all three patients, PET images demonstrated increased FDG uptake in a distribution that correlated with surgical-pathologic findings (100%); on the contrary, CT can detect 33.3% of these patients with malignant diseases and MRI can detect two-thirds of cases. Serum CA-125 was also elevated in all three patients, although one patient showed an equivocal elevation of 25.7 IU/ml.

CONCLUSIONS

Conventional imaging studies are neither sensitive nor specific for detecting recurrent PSPC. In contrast, besides CA-125, PET might offer a relatively effective tool for detecting recurrent primary serous peritoneal carcinoma. Due to the very small number of patients available in this study, considerable research must be performed to clarify the impact of PET on detecting recurrence of PSPC.

Interleukin-1 polymorphisms associated with increased risk of gastric cancer

Helicobacter pylori infection is associated with a variety of clinical outcomes including gastric cancer and duodenal ulcer disease. The reasons for this variation are not clear, but the gastric physiological response is influenced by the severity and anatomical distribution of gastritis induced by H. pylori. Thus, individuals with gastritis predominantly localized to the antrum retain normal (or even high) acid secretion, whereas individuals with extensive corpus gastritis develop hypochlorhydria and gastric atrophy, which are presumptive precursors of gastric cancer. Here we report that interleukin-1 gene cluster polymorphisms suspected of enhancing production of interleukin-1-beta are associated with an increased risk of both hypochlorhydria induced by H. pylori and gastric cancer. Two of these polymorphism are in near-complete linkage disequilibrium and one is a TATA-box polymorphism that markedly affects DNA-protein interactions in vitro. The association with disease may be explained by the biological properties of interleukin-1-beta, which is an important pro-inflammatory cytokine and a powerful inhibitor of gastric acid secretion. Host genetic factors that affect interleukin-1-beta may determine why some individuals infected with H. pylori develop gastric cancer while others do not.

Optimal debulking surgery is an independent prognostic factor in patients with FIGO IIIC primary epithelial ovarian carcinoma

BACKGROUND

Ovarian cancer is a well-known disease with a poor prognosis. Due to the relatively small number of cases in Taiwan, the outcome and prognostic factors of patients with primary epithelial ovarian carcinoma are unknown.

METHODS

We retrospectively studied patients with proven surgical and pathologic (Federation Internationale de Gynecologie et d'Obstetrique) FIGO IIIC primary epithelial ovarian carcinoma. All patients underwent standard staging surgery, including washing cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, retroperitoneal lymphadenectomy, infracolic omentectomy and excisional biopsy of all suspicious lesions followed by adjuvant chemotherapy with four to 12 courses of cyclophosphamide, epirubicin and cisplatin (CEP) or cyclophosphamide, adriamycin and cisplatin (CAP) intravenously, every three weeks. To avoid the coeffects of chemotherapy and surgical procedures upon the outcome, patients who received paclitaxel-based regimens or underwent incomplete surgery were excluded. Ninety-eight patients from 1990 to 1996 were identified.

RESULTS

The mean follow-up time was 28.7 months, ranging from 5.4 months to 105.9 months. The cumulative five-year disease-free survival rate for all patients was 31.6%. Optimal debulking surgery was completed in 41.8% of patients, which contributed to long-term patient survival (54% vs 16%, p < 0.0001), compared to patients without optimal debulking surgery. Optimal debulking surgery was the only statistically significant independent prognostic factor for five-year disease-free survival using multivariate analysis.

CONCLUSIONS

To improve survival of patients with FIGO stage IIIC epithelial ovarian carcinoma, optimal debulking surgery should be performed as the initial form of surgical intervention.