Seasonal variation in semen quality is not associated with fecundity in the Utah Population Database

We determine whether a suspected seasonal variability in semen quality affect subsequent live birth rates. This is a retrospective, cohort analysis of men who provided semen analyses as part of fertility workup through a large andrology lab between 1996 and 2013 and corresponding birth rates using the Utah Population Database (UPDB). Semen parameters were analysed including total motile count (TMC), total sperm count, sperm concentration and progressive motility. Corresponding live births reflect those born in the state of Utah and were derived from birth certificate data available in the UPDB. Descriptive statistics were reported along with linear regression analysis with mixed effected models to test for an interaction between seasonal variation in semen quality and birth rates, accounting for age at the time of the semen analysis and abstinence time. A total of 11,929 patients and 14,765 semen samples were included. Only 3597 men (39% of men) had one or more values outside the World Health Organization reference range for their semen parameters. Linear regression demonstrated a consistent U-shaped relationship between TMC, total sperm count, and sperm concentration and season, with spring and winter yielding the highest values with a decline in the summer and fall. 7319 of these males had recorded live births for a total of 13,502 live births during the study period after a median follow-up of 7.2 years (IQR: 3.9-11.0). We did not find a significant interaction between specific semen parameters for a specific season and subsequent live births. Semen quality was the highest in the spring and winter, however there was no interaction between seasonal variability in semen quality and subsequent births. This is one of the largest studies describing seasonal variation in semen quality in humans.

Multicenter urethroplasty outcomes for urethral stricture disease for patients with neurogenic bladder or bladder dysfunction requiring clean intermittent catheterization

Background

Our objective is to better comprehend treatment considerations for urethral stricture disease (USD) in patients requiring long-term clean intermittent catheterization (CIC). Patient characteristics, surgical outcomes and complications are unknown in this population.

Methods

Six members of the Trauma and Urologic Reconstruction Network of Surgeons (TURNS) participated in a prospective (2009 to present) and retrospective (prior to 2009) database recording patient demographics, surgical approach and outcomes. We included all patients undergoing urethroplasty who perform CIC. Descriptive statistics were used to analyze results.

Results

A total of 37 patients with 39 strictures were included. Bladder dysfunction was characterized as detrusor failure in 35% and neurogenic etiology in 65%. Median stricture length was 3 cm (IQR: 1.5–5.5) with 28% repaired with dorsal onlay buccal mucosal graft, 26% excision and primary anastomosis, 8% dorsal inlay, 8% ventral and dorsal, 8% flap based 8% non-transecting and 15% other. Functional success was 90%: 4 patients required DVIU or dilation due to recurrence, with 2 of those ultimately requiring repeat urethroplasty. 86% of patients returned to CIC; no patients reported new pad use for urinary leakage after urethroplasty. During a median follow-up period of 3.1 years (IQR: 1.0–5.3), no patients underwent urinary diversion.

Conclusions

Urethroplasty is suitable, safe and effective for patients dependent on CIC suffering from USD. The effect of continual CIC on long-term outcomes remains uncertain.

"The Back-up Vasectomy Reversal." Simultaneous Sperm Retrieval and Vasectomy Reversal in the Couple With Advanced Maternal Age: A Cost-Effectiveness Analysis

OBJECTIVE

To determine the cost-effectiveness of different fertility options in men who have undergone vasectomy in couples with a female of advanced maternal age (AMA). The options include vasectomy reversal (VR), sperm retrieval (SR) with in vitro fertilization (IVF), and the combination of VR and SR with IVF, which is a treatment pathway that has been understudied.

MATERIALS AND METHODS

Using TreeAge software, a model-based cost-utility analysis was performed estimating the cost per quality-adjusted life years (QALY) in couples with infertility due to vasectomy and advanced female age over a period of one year. The model stratified for female age (35-37, 38-40, >40) and evaluated four strategies: VR followed by natural conception (NC), SR with IVF, VR and SR followed by failed NC and then IVF, and VR and SR followed by failed IVF and then NC. QALY estimates and outcome probabilities were obtained from the literature and average patient charges were calculated from high-volume centers.

RESULTS

The most cost-effective fertility strategy was to undergo VR and try for NC (cost-per-QALY: $7,150 (35-37 y), $7,203 (38-40 y), and $7,367 (>40 y)). The second most cost-effective strategy was the "back-up vasectomy reversal": undergo VR and SR, attempt IVF and switch to NC if IVF fails.

CONCLUSION

In couples with a history of vasectomy and female of AMA, it is most cost-effective to undergo a VR. If the couple opts for SR for IVF, it is more cost-effective to undergo a concomitant VR than SR alone.

Round spermatid injection into human oocytes: a systematic review and meta-analysis

Many azoospermic men do not possess mature spermatozoa at the time of surgical sperm extraction. This study is a systematic review and meta-analysis evaluating outcomes following round spermatid injection (ROSI), a technique which utilizes immature precursors of spermatozoa for fertilization. An electronic search was performed to identify relevant articles published through October 2018. Human cohort studies in English involving male patients who had round spermatids identified and used for fertilization with human oocytes were included. Fertilization rate, pregnancy rate, and resultant delivery rate were assessed following ROSI. Meta-analysis outcomes were analyzed using a random-effects model. Data were extracted from 22 studies involving 1099 couples and 4218 embryo transfers. The fertilization rate after ROSI was 38.7% (95% confidence interval [CI]: 31.5%-46.3%), while the pregnancy rate was 3.7% (95% CI: 3.2%-4.4%). The resultant delivery rate was low, with 4.3% of embryo transfers resulting in a delivery (95% CI: 2.3%-7.7%). The pregnancy rate per couple was 13.4% (95% CI: 6.8%-19.1%) and the resultant delivery rate per couple was 8.1% (95% CI: 6.1%-14.4%). ROSI has resulted in clinical pregnancies and live births, but success rates are considerably lower than those achieved with mature spermatozoa. While this technique may be a feasible alternative for men with azoospermia who decline other options, couples should be aware that the odds of a successful delivery are greatly diminished and the prognosis is relatively poor.

Impact of paternal age on embryology and pregnancy outcomes in the setting of a euploid single-embryo transfer with ejaculated sperm: retrospective cohort study

Objective

To evaluate the impact of paternal age on embryology and pregnancy outcomes in the setting of a euploid single-embryo transfer.

Design

Retrospective cohort study.

Setting

Not applicable.

Patient(s)

Couples undergoing a first in vitro fertilization cycle with fresh ejaculated sperm who used intracytoplasmic sperm injection for fertilization followed by preimplantation genetic testing for aneuploidy and single-embryo transfer of a euploid embryo between January 2012 and December 2018.

Intervention(s)

Not applicable.

Main Outcome Measure(s)

Embryology outcomes assessed were fertilization rate, blastulation rate, and euploid rate. Pregnancy outcomes assessed included positive human chorionic gonadotropin rate, delivery rate, biochemical loss rate, and clinical loss rate.

Results

A total of 4,058 patients were assessed. After adjusting for female age, increased paternal age in the setting of fresh ejaculated sperm use was associated with decreased blastulation and decreased euploid rate using 40 years as an age cutoff.

Conclusion(s)

In this study, advancing paternal age appears to have a detrimental impact on rates of blastocyst formation and euploid status. However, if a euploid embryo is achieved, older paternal age does not appear to affect negatively pregnancy outcomes.

The Role of the Urologist in a Reproductive Endocrinology and Infertility Practice

With male factor infertility accounting for up to 50% of infertility cases, demand for male fertility services has increased. Integrating a reproductive urologist within a fertility center allows for treatment of both partners simultaneously with easier, more convenient access to a comprehensive male evaluation and any indicated interventions. A joint practice allows urologists to collaborate more closely with reproductive endocrinologists, which can, in turn, improve clinical care and research endeavors. This full-service, streamlined approach translates to optimized care for the infertile couple and allows for emphasis of male partner health.

Baseline Gonadotropin Levels and Testosterone Response in Hypogonadal Men Treated With Clomiphene Citrate

OBJECTIVE

To investigate the role of baseline gonadotropins in predicting the biochemical response to clomiphene citrate (CC) treatment.

METHODS

We conducted a retrospective review of data from hypogonadal men treated with CC in 2 high-volume fertility centers between 2013 and 2018. Patient age, body mass index, and baseline hormones (follicle stimulating hormone [FSH], luteinizing hormone [LH], and total testosterone [TT]) were obtained. Response to treatment was measured as changes in TT levels within 6 months of initiating CC treatment. Linear regression models adjusted for age, body mass index, and time on CC therapy were fitted to assess the associations between baseline LH and FSH levels with treatment response.

RESULTS

A total of 332 men with mean ± standard deviation age of 36.2 ± 8.2 years were included. Median time to initial follow-up was 6 weeks (25th-75th interquartile range [IQR]: 4-9 weeks). TT levels increased significantly on CC treatment (mean change: 329.2 ng/dL, 95% CI: 307.4-351.0) with 73% of men having at least 200 ng/dL increase over baseline TT levels. In univariable linear regression models, only age was significantly associated with TT response. Neither the baseline LH nor FSH significantly predicted TT response in linear regression models.

CONCLUSION

CC treatment results in significant increases in testosterone levels in most men. Baseline gonadotropins are not strong predictors for treatment response to CC. Adequate biochemical response with CC trial can be expected in most patients with normal or slightly elevated baseline gonadotropin levels.

Obesity and Baseline Estradiol Levels Are Independent Predictors for Initiation of Anastrozole in Hypogonadal Men on Clomiphene Citrate

PURPOSE

To assess the conversion rate from clomiphene citrate (CC) monotherapy to combination CC+anastrozole (AZ) therapy in hypogonadal men and the predictors associated with the initiation of AZ.

MATERIALS AND METHODS

A retrospective review of records from hypogonadal men treated with CC in a single fertility center was performed from 2013 to 2018. Patient age, body mass index (BMI), blood pressure, and reproductive hormones were obtained at baseline. Obesity was defined as BMI≥30 kg/m². Cox proportional hazards models were used to identify predictors of switching to combination CC+AZ therapy.

RESULTS

A total of 318 men on CC were included. Median (interquartile range) age was 34 years (30-39 years) and patients were followed for a median of 9 months (4-17 months). Of these, 97 (30.5%) were started on CC+AZ therapy. These patients had higher baseline BMI and estradiol, which in multivariable regression were significant predictors for switching to CC+AZ therapy. A threshold of 18.5 pg/mL for baseline estradiol provided the highest accuracy for predicting the addition of AZ after adjusting for baseline BMI and total testosterone levels.

CONCLUSIONS

In our practice, following CC monotherapy, 30% of men were initiated on CC+AZ. Obesity (BMI≥30 kg/m²) and baseline estradiol ≥18.5 pg/mL can predict the conversion to combination therapy with addition of AZ. This information can be used to counsel patients and also help to identify patients who can be started on combination therapy upfront.

Augmentation cystoplasty in the patient with neurogenic bladder

PURPOSE

To review the indications and techniques of augmentation cystoplasty (AC) in patients with neurogenic bladder (NGB) while also examining the long-term outcomes, complications, and follow-up surgeries.

METHODS

PubMed/MEDLINE, Cochrane Library, and Embase databases were searched for articles related to AC and NGB.

RESULTS

AC is indicated for an overactive or poorly compliant bladder refractory to conservative therapies, such as anticholinergic medications and bladder botulinum toxin injections. A variety of surgical techniques using gastrointestinal segments, alternative tissues, and synthetic materials have been described, though bowel remains the most durable. Ileocystoplasty is the most common type of AC, which uses a detubularized patch of ileum that is anastomosed to a bivalved bladder. Some patients undergo concomitant surgeries at the time of AC, such as catheterizable channel creation to aid with clean intermittent catheterization, ureteral reimplantation to treat vesicoureteral reflux, and bladder outlet procedure to treat incontinence. Following AC, the majority of patients experience an improvement in bladder capacity, compliance, and continence. Most patients also experience an improvement in quality of life. AC has significant complications, such as chronic UTIs, bladder and renal calculi, metabolic disturbances, bowel problems, perforation, and malignancy. AC also has a high rate of follow-up surgeries, especially if the patient undergoes concomitant creation of a catheterizable channel.

CONCLUSIONS

Enterocystoplasty remains the gold standard for AC, though more research is needed to better evaluate the morbidity of different surgical techniques and the indications for concomitant surgeries. Experimental methods of AC with tissue engineering are a promising area for further investigation.

Fertility concerns of the transgender patient

Transgender individuals who undergo gender-affirming medical or surgical therapies are at risk for infertility. Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear. Gender-affirming surgery (GAS) that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility. It is recommended that clinicians counsel transgender patients on fertility preservation (FP) options prior to initiation of gender-affirming therapy. Transmen can choose to undergo cryopreservation of oocytes or embryos, which requires hormonal stimulation for egg retrieval. Uterus preservation allows transmen to gestate if desired. For transwomen, the option for FP is cryopreservation of sperm either through masturbation or testicular sperm extraction. Experimental and future options may include cryopreservation and in vitro maturation of ovarian or testicular tissue, which could provide prepubertal transgender youth an option for FP since they lack mature gametes. Successful uterus transplantation with subsequent live birth is a new medical breakthrough for cisgender women with uterus factor infertility. Although it has not yet been performed in transgender women, uterus transplantation is a potential solution for those who wish to get pregnant. The transgender population faces many barriers to care, such as provider discrimination, lack of information, legal barriers, scarcity of fertility centers, financial burden, and emotional cost. Further research is necessary to investigate the feasibility of experimental FP options, provide better evidence-based information to clinicians and transgender patients alike, and to improve access to and quality of reproductive services for the transgender population.

Outcomes of right colon continent urinary pouch using standardized reporting methods

AIMS

Studies of right colon pouch urinary diversion estimate risk of perioperative complications, 1%-50%, and reoperation, 1%-69%. This wide range is due to variable outcome measurements and reporting methods; it is also unclear which factors increase the risk of complications and reoperation. We sought to characterize the impact of patient-specific factors on risk of complications, readmission, and reoperation after right colon pouch urinary diversion.

METHODS

Patients undergoing right colon pouch urinary diversion from January 2010 to April 2017 were analyzed. Outcomes included: high-grade complications within 90 days (Clavien-Dindo grade ≥3), readmission within 90 days, and reoperation at any time during follow-up. Patient-specific factors were analyzed to establish any associations with these outcomes.

RESULTS

During the study period, 53 patients underwent the procedure and the average follow-up was 30 (standard deviation [SD] 21.5) months; 90-day high-grade complications were 22% and readmission was 45%. The cumulative rate of any reoperation was 53% and major reoperation was 32%. Diabetes was associated with an increased risk of both postoperative complications and reoperation. Larger body mass index and prior abdominal surgery were associated with increased risk of readmission.

CONCLUSIONS

Overall the rate of postoperative complications, readmissions, and reoperation was high, but in agreement with other contemporary series. This study helps to further characterize surgical outcomes after right colon pouch urinary diversion, however, similar to other studies in the literature, the rarity of the procedure limits the power to establish a link between preoperative patient factors and outcomes.

Clinical Use of Expanded Prostate Cancer Index Composite for Clinical Practice to Assess Patient Reported Prostate Cancer Quality of Life Following Robot-Assisted Radical Prostatectomy

PURPOSE

EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) is a short questionnaire that comprehensively measures patient reported health related quality of life at the point of care. We evaluated the feasibility of using EPIC-CP in the routine clinical care of patients with prostate cancer without research infrastructure. We compared longitudinal patient and practitioner reported prostate cancer outcomes.

MATERIALS AND METHODS

We reviewed health related quality of life outcomes in 482 patients who underwent radical prostatectomy at our institution from 2010 to 2014. EPIC-CP was administered and interpreted in routine clinical practice without research personnel. We compared practitioner documented rates of incontinence pad use and functional erections to patient reported rates using EPIC-CP.

RESULTS

A total of 708 EPIC-CP questionnaires were completed. Mean urinary incontinence domain scores were significantly higher (worse) than baseline (mean ± SD 0.6 ± 0.2) 3 and 6 months after treatment (mean 3.1 ± 2.3 and 2.2 ± 2.1, respectively, each p <0.05) but they returned to baseline at 12 months (mean 1.6 ± 1.7, p >0.05). Mean sexual domain scores were significantly worse than baseline (mean 2.4 ± 2.8) at all posttreatment time points (each p <0.05). Practitioners significantly overestimated incontinence pad-free rates at 3 months (48% vs 39%) and functional erection rates at 3 months (18% vs 12%), 6 months (38% vs 23%) and 12 months (45% vs 23%, each p <0.05).

CONCLUSIONS

EPIC-CP is feasible to use in the routine clinical care of patients with prostate cancer without requiring a research infrastructure. Using EPIC-CP in clinical practice may help practitioners objectively assess and appropriately manage posttreatment side effects in patients with prostate cancer.

Genome-wide normalized score: a novel algorithm to detect fetal trisomy 21 during non-invasive prenatal testing

OBJECTIVES

Non-invasive prenatal testing for fetal trisomy 21 (T21) by massively parallel shotgun sequencing (MPSS) is available for clinical use but its efficacy is limited by several factors, e.g. the proportion of cell-free fetal DNA in maternal plasma and sequencing depth. Existing algorithms discard DNA reads from the chromosomes for which testing is not being performed (i.e. those other than chromosome 21) and are thus more susceptible to diluted fetal DNA and limited sequencing depth. We aimed to describe and evaluate a novel algorithm for aneuploidy detection (genome-wide normalized score (GWNS)), which normalizes read counts by the proportions of DNA fragments from chromosome 21 in normal controls.

METHODS

We assessed the GWNS approach by comparison with two existing algorithms, i.e. Z-score and normalized chromosome value (NCV), using theoretical approximations and computer simulations in a set of 86 cases (64 euploid and 22 T21 cases). We then validated GWNS by studying an expanded set of clinical samples (n = 208). Finally, dilution experiments were undertaken to compare performance of the three algorithms (Z-score, NCV, GWNS) when fetal DNA concentration was low.

RESULTS

At fixed levels of significance and power, GWNS required a smaller fetal DNA proportion and fewer total MPSS reads compared to Z-score or NCV. In dilution experiments, GWNS also outperformed the other two methods by reaching the correct diagnosis with the lowest range of fetal DNA concentrations (GWNS, 3.83-4.75%; Z-score, 4.75-5.22%; NCV, 6.47-8.58%).

CONCLUSION

Our results demonstrate that GWNS is comparable to Z-score and NCV methods regarding the performance of detecting fetal T21. Dilution experiments suggest that GWNS may perform better than the other methods when fetal fraction is low.

Endoscopic specimen pouch technique for removal of giant fibroadenomas of the breast

Giant (juvenile or cellular) fibroadenoma of the breast is the most common tumor that present in adolescent girls. As benign tumors that can exceed 10 cm in diameter, giant fibroadenomas have historically necessitated large incisions to remove these masses, resulting in large unsightly scars. We describe the novel use of an endoscopic specimen pouch to facilitate the removal of these large tumors through minimal incisions in 3 patients. In follow-up, all 3 patients have had excellent cosmetic outcomes, no recurrences, and no postoperative complications.

Postpartum urinary retention after cesarean delivery

OBJECTIVE

To investigate the incidence of postpartum urinary retention (PUR) after cesarean delivery and determine which obstetric factors contribute to this problem.

METHOD

A prospective study recruited 605 pregnant women who had a cesarean delivery. Each patient's postvoid residual bladder volume (PVRBV) was estimated with an ultrasound scan after first micturition. The women were divided into 2 groups: PUR (PVRBV > or =150 mL) and normal. Patients' characteristics, obstetric parameters, and prevalence of lower urinary tract symptoms at 3 months postpartum were compared.

RESULT

The overall incidence of PUR was 24.1%. The incidence of overt and covert PUR was 7.4% and 16.7%, respectively. Morphine-related postoperative analgesia, multiple pregnancy, and low body mass index were significantly associated with PUR. At 3-month follow-up, 5.0% of patients had obstructive voiding symptoms and 9.1% had irritative voiding symptoms.

CONCLUSION

Our results revealed PUR was a common phenomenon in patients who had a cesarean delivery, and morphine-related postoperative analgesia was the main contributing factor.

Maternal anxiety about prenatal screening for group B streptococcus disease and impact of positive colonization results

OBJECTIVE

Universal screening for colonization by group B streptococcus (GBS) is the recommended strategy to reduce incidence of colonization in newborns and prevent neonatal GBS-related disease. This study was designed to assess maternal anxiety levels about prenatal screening and psychological impact of positive colonization test results.

METHODS

A total of 71 women who screened positively for GBS colonization and 112 screen-negative women (controls) were recruited. Anxiety levels were measured by the Spielberger State Trait-anxiety Inventory just before the GBS screening test, 1-week after testing, and 1-week after delivery. After delivery of their infants, all participants were asked to respond with a Likert scale line about attitudes toward being tested for GBS colonization.

RESULTS

Women with GBS colonization reported significantly greater psychological distress on state-anxiety scores after the full report was received. The trait- and state-anxiety scores before GBS screen testing and after delivery did not differ between the groups. Both groups of women were strongly positive about being screened for GBS in the current pregnancy and in future pregnancies.

CONCLUSION

Women with GBS colonization did not have a sustained increase in anxiety; therefore, clinician concerns about causing maternal anxiety should not be an impediment to test for GBS.

Elevated second-trimester maternal serum hCG in patients undergoing haemodialysis

Prenatal Down syndrome screening with maternal serum alpha-fetoprotein (AFP) and human chorionic gonadotrophin (hCG) has become common. High levels of maternal serum hCG and low levels of AFP have been associated with an increased risk of fetal Down syndrome. In this paper, we report five pregnancies in patients undergoing long-term haemodialysis, all of whom had false-positive second-trimester Down syndrome screening results. All of our five patients had extremely high levels of maternal serum hCG, but normal AFP values for their gestational age, and all had serious complications during pregnancy.

Second trimester maternal serum screening using alpha fetoprotein, free beta human chorionic gonadotropin and maternal age specific risk: result of chromosomal abnormalities detected in screen positive for Down syndrome in an Asian population

BACKGROUND

This study was to determine the incidence of chromosome abnormalities in Taiwanese women undergoing prenatal chromosome analysis after a second trimester Down syndrome screening by using maternal age and serum dual-marker testing (alpha-fetoprotein and free-beta unit human chorionic gonadotropin).

METHODS

A total of 10,098 Taiwanese women with pregnancy between 15 and 23 weeks' gestation received second-trimester Down syndrome risk evaluation by dual-marker and maternal age specific risk testing in a single medical center. The study took 22 months. Ninety-seven percent of this study population was less than 34 years old. Ninety-six percent of our cases were screened between 15-20 weeks of gestation. This population was included only after a routine ultrasonography scan for correction of gestational age and exclusion of major structural anomalies. By using an algorithm to detect Down's syndrome, with a risk of 1:270 as a cut-off value, 816 patients were screen-positive for Down syndrome (screen-positive rate 8.0%). Karyotypes were reviewed for 670 (82.1%) mothers who received prenatal karyotype analysis.

RESULTS

Twelve cases of Down syndrome were identified in the screen positive group with an estimated detection rate of 67% (false positive rate 8%). Three cases of Down syndrome were detected in late trimester among the screen-negative group. Seven other fetal chromosome abnormalities were also found among the screen-positive pregnancy. In addition, seven cases were screen-positive for trisomy 18; all of these patients received amniocentesis and only one case was confirmed.

CONCLUSION

These findings indicate that this screening program combining alpha-fetoprotein (AFP), free beta human chorionic gonadotropin (free-hCG) and maternal age-specific would achieve a screening efficiency in Taiwanese populations as comparable to those obtained in Caucasian populations. Our results also suggest that approximately 3% of pregnancies with a positive dual marker and maternal age-specific screen results will have a chromosome abnormality despite having a normal routine ultrasound scan. Mothers with positive screening results should be made aware of the implications of a positive result.

Thoracoamniotic shunting for treatment of fetal bilateral hydrothorax with hydrops

Isolated bilateral pleural effusion with mediastinal compression leading to hydropic change of the fetus is unusual, and carries a high risk of perinatal death. This condition can be reversed in utero by performing ultrasound-guided shunting surgery. We describe a hydropic fetus at 30 weeks' gestation with rapid recurrence of pleural effusion after thoracentesis. The pleural effusion and hydrops resolved within 1 week after ultrasound-guided thoracoamniotic shunt and the fetal lungs were restored to their normal size. The fetus was born at 35 weeks' gestation and had an uneventful postnatal course. The technique of restoring cardiopulmonary function in utero through intrathoracic decompression offers a valuable alternative to repetitive prenatal thoracentesis or preterm delivery of fetuses with hydrops caused by bilateral pleural effusion.

Ultrasound recognition and treatment of fetal supraventricular tachycardia with hydrops: a case report

To manage fetal tachyarrhythmia induced hydrops, both a correct diagnosis and adequate intrauterine therapy are fundamentally important. We present a 32-week-gestational-age hydropic fetus with supraventricular tachycardia who responded dramatically after transplacental administration of high dose digoxin (1 mg intravenously daily). The baby was born at 36 weeks' gestation followed by a successful postnatal conversion. Prenatal fetal echocardiography is emphasized in determining appropriate treatment and monitoring fetal well-being which in this case resulted in a good outcome.

Isolated fetal ascites: five cases report

Isolated fetal ascites is a rare abnormality that can be detected prenatally by sonography. Fetuses with transient or isolated ascites were reported to have a good outcome if the specific etiology is confirmed and the appropriate treatment is given. In this report, we present 5 cases of nonimmune fetal ascites of different etiologies and obstetric managements. Fetuses that presented with generalized hydrops, chromosomal abnormalities and viral etiologies were excluded. Four of the fetuses survived without major neonatal complications, which included one chyloperitoneum, one meconium peritonitis and 2 idiopathic causes. Spontaneous resolution occurred in three cases. The one treated with prenatal paracentesis did not experience respiratory distress after birth but the other who did not undergo the procedure showed neonatal respiratory distress. The only neonatal mortality was a case involving intestinal obstruction who developed necrotizing enterocolitis four days after the surgery. Nonimmune fetal ascites can have a good outcome by using ultrasound in establishing the specific prenatal diagnosis and surveillance.

Prenatal diagnosis of congenital cystic adenomatoid malformation of the lung: four cases report

Congenital cystic adenomatoid malformation of the lung (CCAML) is a rare pulmonary lesion, characterized by excessive overgrowth of the terminal respiratory bronchioles. Prenatal detection and serial sonographic study of fetuses with CCAML can provide information about the natural history of these lesions and reveal most of the nature history of pathophysiologic features which are likely to affect the clinical outcome. This information is crucial to the formulation of a prognosis and a management strategy. We report on four cases of CCAML, three of which involved macrocystic lesions including two cases of type I and one case of type II. Only one microcystic lesion, a type III CCAML, was identified in these patients. All of the cases were diagnosed by ultrasound between the 21 and 24 weeks of gestation. Fetal hydropic change was noted in all four cases. All of the parents opted for termination of pregnancy before fetal viability. Post-mortem examination confirmed the diagnosis in all four cases.

The detection of right-sided congenital diaphragmatic hernia in monozygotic twins on prenatal ultrasonography

The diagnosis of a pair of monozygotic twins with right-sided diaphragmatic hernia under ultrasound is described. Aspects of heredity, diagnosis and management are discussed.

Obstetrical hysterectomy and placenta previa/accreta: three bladder injury case reports

Pregnancies complicated with placenta previa and a history of cesarean section are well known to be at increased risk for placenta accreta. Bladder injury is occasionally encountered in these patients during operation. From January 1992 to December 1995, 25 obstetrical hysterectomy were performed at Chang Gung Memorial Hospital, Linkou Medical Center. Of these 25 patients three had bladder injury. Ultrasonography is a unique way to screen and detect prenatally the abnormal placentation and intraplacental lacunae. Color Doppler ultrasonic scanning further discloses that the lacunae are mainly venous spaces. Elevated mid-trimester maternal serum x-fetoprotein (MSAFP) frequently leads to a suspicion of the abnormal placentation, and magnetic resonance imaging (MRI) can clearly identify the placenta accreta/increta. Uncontrollable bleeding frequently occurs in these patients during cesarean section, warranting emergency hysterectomy. Emergency obstetrical hysterectomy should be decided upon and performed by an experienced obstetrician. Massive hemorrhage and bladder injury are the major complications encountered in such operations. We review the literature and propose a protocol of management. As the incidence of cesarean section continues to rise world-wide, the problem of placenta previa/accreta is likely to become more common. Obstetricians should be ready to face the late sequelae of today's decision for cesarean section.

Ritodrine-induced leukopenia: a case report and literature review

Ritodrine hydrochloride, a beta 2-adrenergic receptor agonist, has been widely applied in the treatment of premature labor for many years and generally considered as a safe medication. It can however induce some serious side effects, such as pulmonary edema, myocardial ischemia, ketoacidosis, miscellaneous metabolic alterations, and leukopenia. This report presents a rare case of leukopenia in a Chinese woman as a result of low dose continuous intravenous infusion of ritodrine, in which the white blood cell count dropped rapidly and recovered quickly following the cessation of administration. The rapid and spontaneous reversal of leukopenia was most probably due to early recognition and intervention of this drug-induced side effect.

Laparoscopic myomectomy of large symptomatic leiomyoma using airlift gasless laparoscopy: a preliminary report

Despite the expanding role of laparoscopic surgery in many gynaecological fields, some discrepancies still exist regarding the efficacy of laparoscopic myomectomy in treating patients with large symptomatic leiomyoma. In this report, a better operative procedure and the results of treatment are evaluated. Patients (n = 14) presenting with infertility, menorrhagia, pressure symptoms or pelvic mass associated with a large leiomyoma were managed with laparoscopic myomectomy using airlift gasless laparoscopy. Uterine size ranged from 14 to 24 weeks gestational age and the weight of the myoma ranged from 246 to 669 g (mean 454); operative time ranged from 78 to 165 min (mean 104) and blood loss from 90 to 580 ml (mean 201). No major complication occurred during the operation or follow-up. All except one patient were discharged within 72 h of the operation and resumed normal activity within 1 week. When myomectomy is indicated, the airlift gasless laparoscopic approach appears to offer a better alternative to abdominal or pneumoperitoneum laparoscopic surgery in selected cases. Airlift gasless laparoscopy has several advantages: (i) small abdominal incisions and minimal endoscopic equipment are required; (ii) the excised leiomyomata mass can be easily cut into strips and removed through the small abdominal incision; (iii) the uterine defect can be more efficiently repaired using easily performed suture techniques; (iv) high-pressure irrigation and large-volume suction devices can be used without fear of decompressing the pneumoperitoneum; and (v) the potential risk of metabolic and haemodynamic derangements during pneumoperitoneum laparoscopy are obviated. Gasless laparoscopy also has some disadvantages. The exposure obtained with gasless laparoscopy is not as good, under some circumstances, as that achieved by pneumoperitoneum. For patients who are thin, and even those with moderate obesity, the exposure obtained with airlift mechanical suspension is adequate; however, morbidly obese patients with previous abdominal surgery with suspected pelvic adhesions can incur some problems during the operation because of a poor operative field.

Laparoscopic repair of bowel herniation through previous cannula insertion sites

Operative laparoscopy frequently requires large cannulas below or above the umbilicus, which may result in unusual complications such as small bowel herniation through these insertion sites. Three women experienced small bowel herniation through cannula incision sites, either extraumbilically or paraumbilically, after major laparoscopic surgery. Two patients who had undergone laparoscopic myomectomy developed small bowel herniation through the 12-mm extraumbilical cannula site on postoperative days 7 and 8, respectively. In the first woman, the nontender, palpable, and reducible herniation healed spontaneously, with no episode of herniation during follow-up. The second patient required laparoscopic reduction of the herniated loop and repair of the fascial defect. The last woman had undergone laparoscopic-assisted vaginal hysterectomy and developed small bowel herniation through an unrecognized fascial defect paraumbilically 3 days postoperatively. Intended repair by laparoscopy was changed to laparotomy due to extensive and incarcerated bowel herniation.

Extraumbilical insertion of the operative laparoscope in patients with extensive intraabdominal adhesions

In 12 patients who had known or suspected intraabdominal adhesions, we evaluated the benefit of using Palmer's point for inserting the Veress needle and primary cannula during laparoscopic adhesiolysis to prevent direct intestinal injury. After inserting the laparoscope through this point, four women were found to have extreme intestinal adhesions around the umbilical area, and intestinal or severe omental injury might occur if the cannulas were inserted directly through the umbilical fossa. The other eight patients had omentum, partial to severe, adherent to the anterior abdominal wall. No complication occurred during insertion of the Veress needle and primary cannula through Palmer's point. Nine patients had successful laparoscopic adhesiolysis and were discharged within 2 days. In the other three women the procedure was converted to laparotomy because of extensive intestinal adhesions (2 patients) and small bowel injury during laparoscopic adhesiolysis (1). Palmer's point can be considered a safe and good alternative site for inserting the Veress needle and primary cannula to lyse dense intestinal and extensive omental adhesions. This technique should provide the surgeon with wider visual angel and surgical field, thus making adhesiolysis much easier to perform.

Major complications during laparoscopy-assisted vaginal hysterectomy--report of four cases and review of the literature

This paper presents four recent cases of complications resulting from of a total 130 cases of laparoscopy-assisted vaginal hysterectomies performed at Chang Gung Memorial Hospital from March 1991 till January 1993. These included two cases of bladder injury, one case of vessel laceration and one case of colon injury. In addition, the literature about complications occurring at laparoscopy are reviewed and classified. This paper will: 1. present precautionary measures for avoiding intraoperative complications; 2. describe management of complications.

[Lumbosacral lipomas with spinal bifida]

Spinal dysraphism is usually accompanied with lumbosacral lipoma. The neurological deficits such as lower extremities sensorimotor disturbances, bowel and bladder dysfunction are produced by tethering, compression of lipoma and direct transmission of external force on the spinal cord during growth period. 25 patients treated surgically at our hospital between May, 1985, and January, 1993, were reviewed. Surgical approach was designed for debulking the lipomatous mass, untethering and decompressing the cord, repairing the dural defect and paraspinal muscle cleft. 2-59 months (mean 37.5 mons) after operation the 2 patients whose neurological system were normal before operation remained intact. In other 23 patients, bowel function recovered in 75%, active urination restored and improved in 66.2%. Motor dysfunction and paresthesia of the lower extremities alleviated in 78.3%. A case of mild uremia returned to normal and another moderate case improved. None was deteriorated by the operative procedure except one case in which a posterior nerve root was injured.

Ovarian hyperstimulation syndrome with minimal ascites and massive pleural effusion: report of a case

A 30-year-old woman was admitted to the hospital due to bilateral massive pleural effusion and right lung collapse with severe respiratory distress. She had been undergoing gamete intrafallopian transfer (GIFT) following three years of primary infertility. Ovarian stimulation was done with pure follicle stimulating hormone (FSH) and human menopausal gonadotropin (hMG) under pituitary suppression with leuprolide acetate. Bilateral chest pain and progressive dyspnea occurred six days after preovulatory oocytes with washed motile sperms were transferred laparoscopically to the fallopian tubes. Chest radiography, sonography and computed tomography revealed a massive right pleural effusion with right lung collapse, and a mild left pleural effusion. Abdominal sonography revealed minimal ascites. Supportive therapy including fluid supply and albumin infusion failed to improve the respiratory distress. A tube thoracostomy was performed, resulting in rapid reexpansion of the lung. The respiratory distress improved markedly after drainage of 6,800 mL of pleural effusion over 7 days. Massive serosanguineous pleural effusion with minimal ascites is unusual in ovarian hyperstimulation syndrome (OHSS). Tube thoracostomy is a safe and effective treatment for massive pleural effusion and lung collapse in the case of OHSS.

Monoclonal antithyroglobulin antibodies derived from immunizations of mice with human eye muscle and thyroid membranes

A mouse hybridoma clone secreting an immunoglobulin M monoclonal antibody (K-5-4), which reacted with human thyroglobulin (Tg), was obtained from spleen cells of mice immunized with crude membranes of human eye muscle tissues (Em). Its binding to Tg could be inhibited by another monoclonal anti-Tg (F1-11-1) derived from spleen cells of mice immunized with human thyroid cell membranes, but K-5-4 did not inhibit the binding of F1-11-1 to Tg. This finding suggests that K-5-4 may react with a site on the Tg molecule which is susceptible to conformational changes, such as that induced by binding of another anti-Tg antibody at another site on Tg. K-5-4 reacted with human, mouse, rat, guinea pig, bovine, and porcine Tg. Binding and immunohistological staining experiments failed to detect binding of K-5-4 to Em tissue. The very low frequency of one Tg-reacting hybridoma from 6 X 10(8) spleen cells fused after Em immunization contrasts with the relative ease with which monoclonal anti-Tgs were generated from spleen cells of mice immunized with crude human thyroid membranes. In the latter case, 1 anti-Tg hybridoma was generated for every 100,000 spleen cells fused, and an extensive library of monoclonal anti-Tgs was collected. Some of these antibodies were specific for human Tg only, while others cross-reacted with Tg of other animal species. None had the species reativity pattern of K-5-4. The anti-Tgs were used to affinity purify human Tg directly from supernatant of thyroid homogenate; the purified Tg was, in turn, used to affinity purify human polyclonal but monospecific anti-Tg directly from serum of patients in a simple and rapid procedure. We conclude that the monoclonal anti-Tgs are useful reagents in isolating and purifying Tg and anti-Tg.