P–570 Embryos originating from oocytes with smooth endoplasmic reticulum clusters have a lower euploidy rate via PGT-A testing using next-generation sequencing

Study question

Does the presence of smooth endoplasmic reticulum clusters (sERCs) in oocytes affect the human embryo ploidy?

Summary answer

The euploidy rate of embryos originating from sERCs + oocytes is lower

What is known already

While an expert panel strongly recommended that sERCs+ oocytes should not be inseminated, some normal healthy babies derived from sERCs+ oocytes have been reported. In previous studies have shown that declined fertilization rate and lower proportions of good quality embryos are found in oocytes showing sERCs. The updating findings of the molecular status of sERC+ oocytes elucidated the sERCs+ oocytes may have impaired chromosomal segregation ability. However, no study reveals the relation between sERCs and embryo ploidy.

Study design, size, duration

A retrospective study enrolled 129 preimplantation genetic testing (PGT) cycles from January 2017 to March 2020 at Chang Gung Memorial Hospital, Lonkou.

Participants/materials, setting, methods

ICSI fertilization rate, Day5 usable blastocyst rate (D5UBR), total usable blastocyst rate (TUBR), euploidy rate, mosaic rate, and aneuploidy rate are investigated between embryo originating from sERCs+ and sERCs- oocytes.

Main results and the role of chance

Although higher TBUR in blastocyst derived from sERCs+ oocytes than sERCs- group (73.7% vs. 62.5%) but accompanied lower euploidy rate (7% vs. 29%) and higher aneuploid rate (79% vs. 54%).

Limitations, reasons for caution

Limited sample size, need a large-scale study to confirm the conclusion. The live-birth rate per embryo transfer cycle was not included for analysis. As we did not perform polar body analysis, we cannot state for sure that embryonic aneuploidy was related to the oocyte.

Wider implications of the findings: This study demonstrates that embryos originating from sERCs+ oocytes have a lower euploidy rate.

Trial registration number

CMRPG3H0751

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.

Laparoscopic myomectomy for large uterine fibroids. A comparative study

BACKGROUND

The goal of this study was to examine the safety and feasibility of laparoscopic myomectomy (LM) for the management of symptomatic intramural uterine fibroids with weight greater than 80 g as compared to those less than 80 g.

METHODS

In a prospective comparative study, 176 women with symptomatic uterine fibroids were scheduled for LM. They were divided into two groups, one with main uterine fibroid (intramural type) weight greater than 80 g and the other with fibroid weight less than 80 g. Outcome measures for the two groups were studied in terms of operation time, amount of blood loss, requirement of blood transfusion, and length of hospital stay.

RESULT

Operation time and amount of blood loss were significantly greater in the group with fibroid > or = 80 g than in the group < 80 g (121.5 +/- 58.9 min versus 79.1 +/- 28.6 min, p < 0.001; and 346.3 +/- 299.6 ml versus 123.0 +/- 89.7 ml, p < 0.001, respectively). However, there was no difference in the length of hospital stay and overall incidence of operative complications between these two groups. None of the women had any major complications. Nevertheless, 11 minor complications were noted, including two pelvic abscesses requiring a second laparoscopic treatment. There was no incidence of switching to laparatomy during the operation. Extreme intraoperative hemorrhage of more than 1000 ml occurred in 8 patients; however, all progressed to full recovery after blood transfusion. Rate of blood transfusion was significantly lower in the group with fibroid < 80 g (3.2% versus 22.1%, p < 0.001).

CONCLUSIONS

Despite the increased operation time and blood loss, LM can be safely performed in the treatment of large uterine fibroid. However, high risk of blood transfusion in these patients has to be kept in mind.

Pitfalls in the differential diagnosis of a pelvic cyst: lessons from a post-menopausal woman with bladder diverticulum

We present a case of non-obstructive bladder diverticulum in a 75-year-old post-menopausal woman. An ovarian cyst was previously suspected, which resulted in a futile exploratory laparotomy without making any definite diagnosis, 1 year earlier. During this admission, transvaginal ultrasound-guided cyst aspiration was arranged to determine the nature of the presumed 'recurrent' cyst and to relieve the symptoms. Prior to cyst aspiration, up to 700 ml of urine through urinary catheterisation and the gradual disappearance of the 'cyst' alerted us to the possibility of a bladder diverticulum, which was later confirmed by retrograde cystography. This case illustrates the lessons that despite considerable researches having been done on enhancing sonographic accuracy, diagnosis based on imaging alone is likely to be associated with multiple pitfalls. Recognising the common pitfalls and integrating clinical information and alertness with ultrasonic features remains the mainstay of sonographic differential diagnosis.

Interphase FISH--assisted second-trimester termination of a trisomy 21 fetus in an IVF-ET twin pregnancy. A case report

BACKGROUND

When confronting a dizygotic pregnancy with one fetus affected with chromosomal aberrations, most couples would opt for selective termination of the affected twin.

CASE

Routine genetic amniocentesis was performed for an in vitro fertilization-embryo transfer twin pregnancy at 18 weeks' gestation due to advanced maternal age. After two weeks, cytogenetic analysis revealed that both twins were male and one was affected with trisomy 21. At that time, ultrasound examination could not tell them apart with certainty. With the aid of interphase fluorescence in situ hybridization (FISH), we had no trouble locating the affected twin and performed feticide successfully with an intracardiac potassium chloride injection. At 37 weeks of gestation, a normal male was delivered along with a macerated trisomy 21 fetus.

CONCLUSION

In a dizygotic twin pregnancy discordant for chromosome aberrations, when ultrasound cannot distinguish the affected twin, performing interphase FISH with an appropriate chromosome probe proves very useful in quickly and accurately locating the chromosomally abnormal twin for selective termination.

Comparison of transdermal and oral estrogen-progestin replacement therapy: effects on cardiovascular risk factors

OBJECTIVE

To determine the effects of oral and transdermal hormone replacement therapy on lipid profile and hemostatic factors in postmenopausal women.

DESIGN

Twenty subjects were treated with oral E2 valerate (2 mg) combined with cyproterone acetate (1 mg) (group I) and 21 with transdermal E2 (1.5 mg) plus oral medroxyprogesterone acetate (5 mg) (group II). The effects on lipid profile and hemostatic parameters were evaluated at baseline and after 3, 6, and 12 months of treatment.

RESULTS

Group I showed a stronger increase of high-density lipoprotein (HDL) cholesterol levels (2-8%) and stronger reduction of atherogenic indices (total cholesterol/HDL cholesterol and low-density lipoprotein/HDL cholesterol) than group II. Group II showed a more pronounced reduction of triglyceride (21-31%) and factor VII (6-10%) levels than group I. Both groups showed reduced concentrations of total cholesterol, low-density lipoprotein cholesterol, tissue plasminogen activator, plasminogen activator inhibitor-1, antithrombin III, and protein S, whereas protein C was increased after 12 months of treatment.

CONCLUSIONS

The cardioprotective effects of hormone replacement therapy are demonstrated by favorable effects on lipid profile and fibrinolytic activity. Oral hormone replacement therapy showed a more prominent effect on lipoprotein metabolism than did transdermal administration, but transdermal medication had a stronger effect on triglyceride and coagulation factors. However, it needs to be considered that there is an increased risk of venous thrombotic events in the first year of treatment.

Three-dimensional ultrasonic images of normal fetus

BACKGROUND

The purpose of this study was to assess the usefulness and feasibility of 3-dimensional (3D) ultrasound for routine fetal observation.

METHODS

Eighty-five normal pregnancies with gestational ages of 20-36 weeks were studied. A conventional ultrasound scanner with a specially designed operation unit, frame memory, and 3D probe was the apparatus used in this study. The unit has a circuit board consisting of digital integrated circuit chips designed to make calculations of volume ray tracings for volume rendering in real time. For each fetus, scanning was performed with different levels of opacity in the equation for volume rendering. In areas where there was an inadequate amniotic fluid pocket to perform an adequate examination, the pregnant woman was asked to push the fetus to the opposite side by gently pressing on her abdomen.

RESULTS

Face, limbs, and fingers which are difficult to visualize on conventional ultrasonography could be seen clearly. Extremely satisfactory images were obtained at between 24 and 34 weeks of gestation that produced sonographic pictures easily recognized even by laypersons. Beyond 34 weeks of gestation due to the relative decrease in the size of amniotic fluid pockets, and before 24 weeks of gestation due to frequent fetal movement, the soft tissue of fetuses is thin and its acoustic impedance is virtually the same as that of water, so surface-rendered images are less satisfactory. In addition, the anterior wall placenta, multiple pregnancies, and oligohydramnios made viewing even more difficult.

CONCLUSION

Between 24 and 34 weeks of gestation, 3D ultrasound is a feasible and useful procedure for routine antenatal examination.

Classification for endoscopic treatment of mullerian anomalies with an obstructive cervix

STUDY OBJECTIVE

To describe our classification according to severity of developmental mullerian anomalies with obstructed cervix.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

Ten women with developmental mullerian anomalies with obstructed cervix.

INTERVENTION

Patients with didelphic uterus with a rudimentary nonfunctional horn and hypoplastic cervix (type 1) underwent hemihysterectomy or diagnostic endoscopy. Those with agenesis of cervix with normal uterus (type 2) had uterovaginal canalization or neocervix with full-thickness skin graft. Women with identical didelphic uteri and hypoplastic cervix (type 3) underwent uterovaginal canalization with or without endometrial ablation or hemihysterectomy. Patients with didelphic uterus with a rudimentary horn and hypoplastic cervix (type 4) had laparoscopic hemihysterectomy. Those with agenesis of the vagina and cervix but with functional endometrium (type 5) had laparoscopic-assisted full-thickness skin graft.

MEASUREMENTS AND MAIN RESULTS

Average duration of surgery was 60 to 210 minutes. There were no intraoperative complications. Patients with type 1 anomaly are continuing infertility treatment. All three patients in type 2 continue to have regular menses without dysmenorrhea. In those with type 3 conditions, hemihysterectomy was performed in one woman and uterovaginal canalization was performed on the hypoplastic cervix in another. After the neocervix was created, endometrial ablation was performed. No evidence of cervical obstruction or hematometra was found in either patient. The patient with type 4 anomaly continues to have regular menstrual periods without dysmenorrhea. Women with type 5 disorder had good healing of vaginal skin grafts.

CONCLUSION

This classification helps identify mullerian anomalies in relation to obstructive cervix. It is useful in categorizing the disorders and determines management strategies and prognosis.

Extraperitoneal approach to laparoscopic Burch colposuspension

STUDY OBJECTIVE

To evaluate 3-year outcomes of extraperitoneal laparoscopic colposuspension in treating genuine stress incontinence.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

One hundred sixty women with genuine stress incontinence with bladder neck hypermobility.

INTERVENTION

Extraperitoneal space was created with CO2 through a 10-mm midline port 2 cm above the pubic hairline. A pair of sutures was inserted at the level of midurethral and urethrovesical junction, fixing them to Cooper's ligament on each side with proper tension.

MEASUREMENTS AND MAIN RESULTS

Of 160 women, 10 were lost to follow-up. On follow-up questionnaire sent to 150 patients, 148 (98.7%) were pleased with the results of surgery. Stress incontinence was cured in 136 women (90.7%) after a minimum of 3 years' follow-up.

CONCLUSION

Cure rates for extraperitoneal colposuspension were similar to those reported for traditional laparoscopic or laparotomy Burch procedures; however, this is a more direct method to expose the space of Retzius, thus eliminating the need to open and close peritoneum.

Short- and long-term effects of hormone replacement therapy on cardiovascular risk factors in postmenopausal women

BACKGROUND

The beneficial effect of hormone replacement therapy (HRT) on cardiovascular disease has been documented in postmenopausal women, but has a significant time trend. Thus, it is worthwhile to further study whether there are different effects on cardiovascular factors between short- and long-term use of HRT.

METHOD

Prospective study of the changes on lipoprotein profile, hemostatic factors, and platelet aggregation was evaluated in 21 postmenopausal women receiving oral E2 valerate (2 mg/d) combined with medroxyprogesterone acetate (10 mg/d) during the last 10 days of each 21-day cycle. The treatment period was 24 months.

RESULTS

During the 24 months of treatment, total cholesterol, low-density lipoprotein cholesterol (LDL-C), and atherogenic indices- total cholesterol-to-high-density lipoprotein cholesterol (HDL-C) and LDL-C-to-HDL-C, were significantly reduced. The concentrations of tissue plasminogen activator and plasminogen activator inhibitor-1 were significantly reduced after 12 months of HRT. In addition, the concentrations of antithrombin III were significantly increased, but protein S was statistically decreased during the 18 months of HRT. The maximum aggregation and slope of platelet aggregation were significantly reduced only during the first 12 months of HRT.

CONCLUSION

This study demonstrates that there were some differences in cardiovascular risk factors between short- and long-term HRT, especially in changes in platelet aggregation and hemostatic factors. However, the long-term favorable effect on lipoprotein metabolism and fibrinolytic activity among hormone users may explain, in part, the inverse association between HRT and cardiovascular disease.

Negative predictive value of human papillomavirus test following conization of the cervix uteri

OBJECTIVE

The goal of this study was to determine/evaluate the negative predictive value of human papillomavirus (HPV) testing following conization of cervix uteri.

METHODS

A prospective analysis was undertaken on 79 cone biopsies of women with high-grade lesions (cervical intraepithelial neoplasia (CIN) III). HPV testing was performed on cervical smears before and after conization. We correlated the margin status (defined as positive cone margin or endocervical curettage status) and positive conization HPV status with the residual disease in a hysterectomy specimen. A Digene II kit was used to perform HPV testing. HPV detection was done by Hybrid Capture assay.

RESULTS

Of the 79 patients, 47(59.5%) had positive margins after conization. HPV testing was positive in 37 cases (78.7%) and negative in 10 cases (21.3%). Residual disease was found in 31 of 47 (66%) postconization hysterectomy specimens. No residual lesions were found in HPV-negative cases. Of the 32 cases with negative margins following conization, HPV testing was negative in 25 cases (78%) and was positive in 7 cases (22%). Among these 25 cases with negative HPV tests, no residual lesion was detected, and in 7 HPV-positive cases, only one residual lesion was found.

CONCLUSION

HPV testing is potentially an effective tool in predicting residual dysplasia after conization and could potentially assist in the decision between hysterectomy and conservative follow-up in women with CIN III.

Applications of the telomerase assay in peritoneal washing fluids

OBJECTIVE

The aim of this study was to detect telomerase activity in peritoneal ascites and to assess whether it can be used as an assistant tool for the early detection of ovarian cancer.

METHODS

Telomerase activity was measured by TRAP assay in 47 patients with ovarian malignancies and 50 patients with benign uterine leiomyomas (control group).

RESULTS

All 26 peritoneal washing cytology positive cases were telomerase positive. Of the 21 peritoneal washing cytology negative cases, 3 were telomerase positive. When these 3 were reevaluated for peritoneal cytology, malignant ascitis was identified in 1. All telomerase negative cases were negative for peritoneal washing cytology. The sensitivity and specificity of peritoneal cytology and telomerase testing in correlation with true malignant cells were 96 (26/27) and 100% (20/20) versus 100 (27/27) and 90% (18/20), respectively. The false negative rate of peritoneal cytology was 4.7% (1/21). The false positive rate of the telomerase test in relation to malignant ascites was 6.9% (2/29).

CONCLUSION

Our preliminary results reveal a high sensitivity and specificity of both telomerase testing and conventional cytology in peritoneal fluids. Our data suggest that the telomerase test in peritoneal fluids can be used as an adjuvant to cytopathological methods in the diagnosis of malignant peritoneal ascites, particularly in cases of negative cytology. In these cases, a review of peritoneal histocytology is advised.

Microlaparoscopically assisted vaginal hysterectomy. A preliminary report

OBJECTIVE

To evaluate the clinical possibility of using a microlaparoscope in laparoscopically assisted vaginal hysterectomy.

STUDY DESIGN

Twenty-five women with different indications for hysterectomy and a uterine size < 14 weeks' gestation underwent laparoscopically assisted vaginal hysterectomy using a microlaparoscope and 2-mm instruments.

RESULTS

Microlaparoscopic procedures included coagulation and separation of infundibulopelvic or uteroovarian round ligaments, vesico-uterine-visceral peritoneal fold dissection, and anterior and posterior colpotomy. The mean operative time, blood loss and length of hospital stay were 84.40 +/- 16.85 minutes, 262.00 +/- 112.99 mL and 3.08 +/- 0.64 days, respectively. No patients developed serious complications, but there were two minor ones.

CONCLUSION

Microlaparoscopy appears to be an efficacious alternative treatment option in well-selected patients undergoing laparoscopically assisted vaginal hysterectomy.

Laparoscopic diagnosis and management of Fitz-Hugh-Curtis syndrome: report of three cases

Perihepatic adhesions between the liver capsule and the diaphragm or the anterior peritoneal surface characterizes Fitz-Hugh-Curtis syndrome (FHCS). FHCS is an extrapelvic manifestation of pelvic inflammatory disease and usually refractory to medical treatment and surgical intervention. With the increased incidence of pelvic inflammatory disease, chronic pelvic pain and sequalae of the process are becoming more common. Herein, we report 3 patients with pelvic inflammatory disease in whom medical treatment failed initially and FHCS was diagnosed via laparoscopy. Laparoscopic lysis of pelvic and perihepatic adhesions, irrigation of the abdomino-pelvic cavity, and antibiotics treatment after surgery successfully relieved these patients' symptoms. FHCS is not a new syndrome but most gynecologists might neglect this condition. Laparoscopy is a less invasive procedure than exploratory laparotomy. We recommend laparoscopy in patients with lower abdominal and right upper quadrant discomfort when other organic disease has been ruled out and medical treatment has failed to relieve symptoms.

First trimester diagnosis of holoprosencephaly and cyclopia with triploidy by transvaginal three-dimensional ultrasonography

We present the prenatal three-dimensional (3D) ultrasound findings in a case of holoprosencephaly and cyclopia at 11 weeks gestation. Only holoprosencephaly with missing cyclopia were initially diagnosed because suboptimal views of the fetal face were obtained with transvaginal two-dimensional (2D) ultrasonography due to fetal position. Chromosomes identified by analysis of a fluid sample from early amniocentesis demonstrated a triploidy (69, XXX), spontaneous fetal demise occurred at 12 weeks and the pregnancy was terminated. This case demonstrated the usefulness of transvaginal 3D ultrasonography in establishing the final diagnosis.

Gonadotropin-releasing hormone messenger ribonucleic acid and protein expression in Vero cells

PURPOSE

Interleukin-1 (IL-1) is a major regulator of local cellular interactions during embryonic implantation. We hypothesized that gonadotropin-releasing hormone (GnRH) may also play a role in the embryonic/epithelial dialogue during early implantation. To examine this hypothesis, we examined the ability of IL-1 to regulate GnRH mRNA and protein expression in Vero cells.

METHODS

Viable Vero cells (1 x 10(5)/well) were cultured in multiple-well tissue culture plates for in vitro studies and in 4-well chamber slides for immunohistochemical study. Confluent Vero cells were cultured with increasing concentrations of recombinant human IL-1 beta for an additional 24 hr. Vero cell expression of GnRH and GnRH receptor mRNAs was measured with polymerase chain reaction (PCR) and nested PCR, respectively. GnRH protein expression was validated by immunohistochemistry study. The quantitative level of GnRH mRNA expression regulated by IL-1 beta in Vero cells was determined by quantitative competitive PCR (QC PCR) with standard curve methodology.

RESULTS

RT-PCR revealed beta-actin, GnRH, and GnRH receptor mRNA expression in Vero cell cultures. Immunostaining confirmed the presence of GnRH protein in Vero cells. Quantitative PCR demonstrated IL-1 beta up-regulation of Vero cell GnRH mRNA expression (p < 0.05).

CONCLUSIONS

These results suggest that Vero cell mRNA and protein expression of GnRH may play a substantial role in early embryo/epithelial dialogue during embryo coculture, with an embryotrophic effect due to expression of GnRH by Vero cells.

Phenotype II triploid pregnancy and study of the parental origin of the extra set of chromosomes with fluorescence microsatellite analysis: case report

Triploidy can reflect diandry (dispermy or diploid sperm) or digyny(diploid ovum). The former is likely to result in the type I phenotype with a partial mole with an appropriate-for-gestational age fetus rarely surviving beyond 20 weeks and a large, cystic placenta. The latter, however, is characterized by a type II phenotype with severe intrauterine growth retardation (IUGR) with longer in utero survival and a small, non-molar placenta. We report on a 22-year-old woman, gravida 2, para1, in the 31st week of gestation who was referred to our prenatal clinic for evaluation of severe IUGR and oligohydramnios. Late cytogenetic karyotyping from cordocentesis revealed a triploidy of 69, XXX. In the 33rd week of gestation, the mother went through spontaneous labor delivering an IUGR 1180 gm fetus and a small, non-molar placenta. The fetus died immediately and was sent for autopsy. In addition to cleft lip and palate, the infant had pulmonary lobation abnormalities. Fluorescence microsatellite analysis of fetal and parental samples confirmed that the extra set of chromosomes present in the proband was a result of a maternal meiosis I nondisjunction error. This may help study of genomic imprinting on human development.

Interleukin (IL)-1beta regulation of IL-1beta and IL-1 receptor antagonist expression in cultured human endometrial stromal cells

The interleukin (IL)-1 system is a major regulator of local cellular interactions during embryonic implantation. Because IL-1beta and IL receptor antagonist (IL-1ra) are both expressed in human endometrium, we hypothesized that an appropriate ratio of IL-1beta to IL-1ra might favor the process of embryo implantation. Therefore, we investigated IL-1 regulation of the quantitative ratio of IL-1beta/IL-1ra messenger RNA (mRNA) expression in human endometrial stromal cells using quantitative competitive PCR, as well as intracellular protein expression after stromal cell solubilization. Confluent stromal cell cultures were stimulated with human IL-1beta (0-1000 IU/mL) for 24 h. After 24 h, total RNA was extracted, reverse transcribed, and coamplified by PCR with a defined amount of internal standard. The quantitative ratio was determined by the density of target to the internal standard. After culture with IL-1beta for 24 and 48 h, stromal cells were solubilized, and the intracellular protein levels of IL-1beta and IL-1ra were measured by enzyme-linked immunosorbent assay. The IL-1beta and IL-1ra mRNA were both up-regulated, and IL-1R tI mRNA was down-regulated, by IL-1beta in a dose-dependent manner. The quantitative ratio of IL-1beta to IL-1ra mRNA was constant with the presence of increasing concentrations of IL-1beta (1-1000 IU/mL). IL-1beta and IL-1ra protein was not detected in conditioned media of cultures before addition of IL-1beta. IL-1beta and IL-1ra protein levels increased with increasing amounts of IL-1beta after solubilization of stromal cells. The IL-1beta was detectable after 12 h of culture, in comparison with IL-1ra, which was detectable after 24 h of IL-1beta stimulation. These results suggest that IL-1 may play a crucial role in embryo-maternal interaction by regulating stromal cell expression of IL-1beta and IL-1ra, resulting in an appropriate ratio during the process of embryonic implantation.

Concomitant closure of patent canal of Nuck during laparoscopic surgery: case report

Indirect inguinal hernia is neglected by many female patients. When women undergo laparoscopy for infertility work-up or other gynaecological conditions, the hernia appears pressurized by the pneumoperitoneum. A large opening on the peritoneum followed by the patent canal of Nuck-as seen in the patient in this case report-is accompanied by a bulge above the labia major. This situation was treated with simple ligation of the canal of Nuck from the internal inguinal ring, and the vulvar bulging mass quickly disappeared, even while under pneumoperitoneal pressure. Laparoscopic hernia repair is currently performed with a mesh prosthesis to cover the defect; however, in female patients it seems unnecessary to use such an invasive method designed largely for males. According to our experience, the concomitant simple closure method for female indirect inguinal hernia is a quick and simple procedure, and deals with the problem during the same laparoscopy. In addition, disappearance of the bulging mass under the pneumoperitoneum offers a useful diagnostic test to secure hernia management.

Uterovaginal canalization and endometrial ablation of the obstructed uterine horn with hypoplastic cervix in the didelphic uterus

Maldevelopment of the mullerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix. Two women with this anomaly experienced symptoms including recurrent lower abdominal pain off and on of 1 to 2 years' duration. Magnetic resonance imaging revealed a double uterus with right hematometrium both patients. After hysteroscopic identification of hypoplasia of right uterine cervix, laparoscopic resection of the hematosalpinx, followed by uterovaginal canalization and prophylactic endometrial ablation of the right uterus was successfully performed by resectoscope. Normal menstruation ensued during follow-up of 18 and 24 months, respectively. Our experience suggests that uterovaginal canalization with prophylactic endometrial ablation may be an efficacious alternative to hysterectomy for management of didelphic uterus with a hypoplastic cervix. (J Am Assoc Gynecol Laparosc 8(1):151-153, 2001)

Laparoscopic closure of patent canal of Nuck for female indirect inguinal hernia

STUDY OBJECTIVE

To determine the efficacy of concomitant laparoscopic closure of the patent canal of Nuck in treatment of indirect inguinal hernias in women.

DESIGN

Prospective clinical trial (Canadian Task Force classification II-2).

SETTING

University-associated tertiary care referral center.

PATIENTS

Six women scheduled for laparoscopy for gynecologic indications. Intervention. Concomitant simple closure of the patent canal of Nuck from the peritoneal cavity during laparoscopic surgery.

MEASUREMENTS AND MAIN RESULTS

Inguinal hernias were repaired in all six patients, with no recurrence.

CONCLUSION

l Laparoscopic closure of the patent canal of Nuck is an easy, safe, and effective treatment of indirect inguinal hernias in women. (J Am Assoc Gynecol Laparosc 8(1):143-146, 2001)

A new portal for gynecologic laparoscopy

We used the middle upper abdomen as a primary port insertion as an alternative portal for laparoscopy and multiport operative pelviscopy in 188 women who were at high risk for subumbilical adhesions because of previous abdominal surgeries or history of gynecologic cancer. Primary cannula insertion was in the middle upper abdomen between xyphoid process and umbilicus (Lee-Huang point). This was the single entry site for the Veress needle and primary laparoscopy port. In 184 (98.4%) of 188 women surgery was performed without complications. No procedure was converted to laparotomy due to visceral or vascular injuries. Two omentum injuries from primary port insertion were repaired with bipolar electrocoagulation; a colon injury was repaired with laparoscopic sutures. In our experience, this laparoscopic port is effective in women who have had abdominal surgery or gynecologic malignancy. (J Am Assoc Gynecol Laparosc 8(1):147-150, 2001)

Ultrasonographic and urodynamic evaluation after tension free vagina tape procedure (TVT)

BACKGROUND

This study was carried out to evaluate the urodynamic and ultrasonographic findings after tension-free vagina tape (TVT) procedure on stress urinary incontinent women.

METHODS

Ninety women suffering from genuine stress incontinence without pelvic relaxation syndrome underwent surgery. Urodynamic measurement, one-hour pad test and introital ultrasonographic evaluation were performed preoperatively and one year after surgery. Additional ultrasonographic surveillance of the urethra was performed immediately after the operation. The position and mobility of the bladder neck was compared pre- and post-operatively in relation to the inferior edge of the pubic symphysis.

RESULT

Eight women were excluded for various reasons. Among the 82 women who completed the study, 76 (93%) were cured, four were improved and two failed. No major intra- or post-operative complications occurred. The position and mobility of the bladder neck showed no significant difference before and after surgery. A urethral knee angle was noted ultrasonographically on cured and improved patients during maximum straining. Nine patients with immediate postoperative voiding difficulty were found to have a pronounced mid-urethra angulation. The symptom and sign were resolved by time after urethra depressing. Urodynamic assessment of the urethral pressure profile and other parameter showed no significant difference before and after the surgery except that a positive pressure transmission in the middle portion of the urethra was noted among 70 (87.5%) of cured and improved subjects.

CONCLUSION

Tension-free vagina tape operation is an effective surgical procedure for the treatment of female urinary stress incontinence. The procedure seems neither to change hypermobility nor to elevate the position of bladder neck. Urinary continence after surgery is most probably achieved by creating a dynamic mid-urethral knee angulation by which the urethra is closed i.e. kinked at stress. Lifting of the mid-urethra resulted in postoperative voiding difficulty. It is the important that the tape is placed tension free under the urethra. Introital ultrasonographic surveillance is a suitable technique to visualize the result of the operation.

Changes in mRNA expression of insulin-like growth factors and insulin-like growth factor-binding proteins in ovarian granulosa cells after cotreatment with growth hormone in low responders

BACKGROUND

Insulin-like growth factors (IGFs) in the intraovarian autocrine control mechanism may serve as a central signal, and the granulosa cell is their site of production, reception, and action. In addition, various IGF-binding proteins (IGFBPs) are thought to modulate and regulate the actions of IGFs and in turn influence the growth and maturation of ovarian follicles.

METHODS

To further investigate the follicular growth and maturation regulated by IGFs and IGFBPs in the ovary of low responders, 14 cases of low responders cotreated with growth hormone (GH) were studied. Another 14 normal responders without GH treatment were also recruited as controls.

RESULTS

Serum levels of estradiol on day 6 and day 9 of the cycle and on the day of HCG administration, and the numbers of oocytes retrieved and follicles on the day of oocyte retrieval were significantly lower in low responders before growth hormone (GH) treatment than those in low responders after GH treatment as well as those in normal responders. Expression of both IGF-II and IGFBP-1 mRNA was elevated (by 23% and 35%, respectively) in granulosa cells from low responders after GH treatment as compared to that in low responders before GH treatment. In contrast, there was a substantial decrease (16%) in expression of IGFBP-3 mRNA in granulosa cells from low responders after GH treatment. Clinically, the pregnancy rate was lower in low responders after GH treatment as compared to controls (7% vs. 29%).

CONCLUSION

Cotreatment with growth hormone in low responders might not increase the pregnancy rate.

Laparoscopic-assisted vaginal myomectomy

STUDY OBJECTIVE

To evaluate the safety and efficacy of combined laparoscopic and vaginal approach in dealing with uterine myomas.

DESIGN

Retrospective case study (Canadian Task Force classification II-2).

SETTING

Tertiary care major teaching hospital.

PATIENTS

Thirty-one women with symptomatic fundal and/or posterior wall uterine myomas.

INTERVENTION

Laparoscopic-assisted vaginal myomectomy performed by one of the authors from July 1996 to December 1998.

MEASUREMENTS AND MAIN RESULTS

Mean +/- SD operating time, blood loss, and length of hospital stay were 79.19+/-18.31 minutes, 150.00+/- 103.28 ml, and 3.10+/-0.75 days, respectively. No patients developed serious complications, and only two minor complications occurred.

CONCLUSION

After laparoscopic inspection and location of uterine myomas, dealing with posterior and fundal uterine myomas by the vaginal route makes hemostasis and uterine repair easier than by purely laparoscopic approach.

Prediction of pregnancy rate of in vitro fertilization and embryo transfer in women aged 40 and over with basal uterine artery pulsatility index

PURPOSE

The purpose was to determine the effect of basal uterine perfusion on the pregnancy rates of in vitro fertilization and embryo transfer (IVF-ET) in women aged 40 and above.

METHODS

A total of 47 patient aged 40 and over underwent IVF-ET. The conception cycles and the nonconception cycles were compared.

RESULTS

Of the 47 patients, 4 patients were pregnant (8.5%). The mean age, basal follicle stimulating hormone (FSH), basal estradiol (E2) level, antral follicle count (AFC), number of ampoules of gonadotropin used, E2 levels and endometrial thickness on the day of human chorionic gonadotropin (hCG) administration, number of retrieved and fertilized oocytes, and number of transferred embryos were not statistically significant between the conception and nonconception cycles. However, the basal uterine artery pulsatility index (UA PI) was significantly lower in the conception cycles (P < 0.001). The receiver operating characteristics (ROC) curve analysis for basal FSH, AFC, and basal UA PI in predicting the pregnancy rate of IVF in patients aged > or = 40 were demonstrated. The best prediction rate was achieved by a pulsatility index cutoff of < 2.0 for a receptive uterus.

CONCLUSIONS

Increased uterine perfusion in the early follicular phase enhanced the pregnancy rate of IVF in women aged 40 and above. It is therefore essential that patients aged > or = 40 with poor basal uterine perfusion should be identified early in the early follicular phase of the menstrual cycle to apply appropriate intervention to improve the uterine circulation for the subsequent chance of pregnancy.

Cyclic changes in serum levels of insulin-like growth factor binding protein-1 in women treated with clomiphene citrate and tamoxifen

In order to investigate the cyclic changes of serum insulin-like growth factor-I (IGF-I), IGF binding protein-1 (IGFBP-1) and IGFBP-3 levels in menstrual cycles treated with or without antiestrogens (clomiphene citrate and tamoxifen), we treated 24 young women having irregular menstrual cycles with either clomiphene citrate (100 mg/day) (n = 12) or tamoxifen (60 mg/day) (n = 12) from the 5th to the 9th day of the menstrual cycle. Without antiestrogens, 12 women with regular menstrual cycles were recruited as controls. There was a preovulatory (day 13) peak of circulating IGFBP-1 in women treated with or without antiestrogens. A significant concomitant increase in serum estradiol was also observed on day 13 of the menstrual cycle in subjects treated with clomiphene citrate and in controls. However, no significant elevation in preovulatory estradiol was detected in women treated with tamoxifen. In clomiphene citrate and control groups, a significant positive correlation was found between circulating IGFBP-1 and estradiol, and between serum levels of IGFBP-1 and inhibin A at the preovulatory stage (on day 13). In contrast, no such association was observed in the tamoxifen group. Unlike cyclic changes in circulating IGFBP-1, serum concentrations of IGF-I and IGFBP-3 remained unchanged throughout the menstrual cycle in all groups. In conclusion, the preovulatory peak of circulating IGFBP-1 can be induced in cycles treated with both clomiphene citrate and tamoxifen. In addition, a significant positive correlation between estradiol, inhibin A and IGFBP-1 at the preovulatory stage indicates that IGFBP-1 may also reflect follicular development and may further be used as an additional indicator to monitor folliculogenesis under clomiphene citrate treatment.

Paclitaxel-induced cell death: where the cell cycle and apoptosis come together

BACKGROUND

Compelling evidence indicates that paclitaxel kills cancer cells through the induction of apoptosis. Paclitaxel binds microtubules and causes kinetic suppression (stabilization) of microtubule dynamics. The consequent arrest of the cell cycle at mitotic phase has been considered to be the cause of paclitaxel-induced cytotoxicity. However, the biochemical events, downstream from paclitaxel's binding to microtubules, that lead to apoptosis are not well understood.

METHODS

The authors examined recent scientific literature about the mechanisms by which paclitaxel exerts cytotoxicity.

RESULTS

In addition to an arrest of the cell cycle at the mitotic phase in paclitaxel-treated cells, recent discoveries of activation of signaling molecules by paclitaxel and paclitaxel-induced transcriptional activation of various genes indicate that paclitaxel initiates apoptosis through multiple mechanisms. The checkpoint of mitotic spindle assembly, aberrant activation of cyclin-dependent kinases, and the c-Jun N-terminal kinase/stress-activated protein kinase (JNK/SAPK) are shown to be involved in paclitaxel-induced apoptosis. Consistent with observations that microtubules of different status (e.g., cytoskeletal microtubules vs. mitotic spindles) have different sensitivity to paclitaxel, the concentration of paclitaxel appears to be the major determinant of its apoptogenic mechanisms.

CONCLUSIONS

Advances in research of the cell cycle and apoptosis have extended our understanding of the mechanisms of paclitaxel-induced cell death. Further elucidation of resistance and enhancement of paclitaxel-induced apoptosis should expedite the development of better paclitaxel-based regimens for cancer therapy.

Radical laparoscopic surgery for carcinoma of the cervical stump

Traditionally, most women with cervical stump cancer underwent radiation therapy, as radical surgery was considered difficult. Given our success performing laparoscopic-assisted radical vaginal hysterectomy, we modified that technique to treat two women with carcinoma of the cervical stump. At follow-up of 14 and 17 months, respectively, both patients were free of recurrence.

Spleen laceration, a rare complication of laparoscopy

A 31-year-old woman had secondary infertility of 4 years' duration. Hysterosalpingography revealed bilateral distal tubal occlusion with bilateral hydrosalpinx-like appearance. At laparoscopy, both oviducts were occluded with marked hydropic change. Salpingoplasty was performed to correct bilateral hydrosalpinges and reform the fimbriated tubal ends. The procedure was performed uneventfully by an experienced surgeon in 45 minutes. Nine hours after the operation an emergency exploratory laparotomy was performed due to massive intraabdominal bleeding. The cause was a small tear, 3 cm long and 1 cm deep, with active bleeding in the inferior splenic tail. The laceration was repaired successfully with 1-0 chromic suture. The etiology of splenic laceration during laparoscopic surgery is uncertain. Many complications of laparoscopy are physiologic, and this one might have occurred while establishing pneumoperitoneum. Distortion and stretching of small vascular adhesions of the spleen with the abdominal wall also may have played a role. Gynecologists must be aware of the physiologic insult to patients during laparoscopy.

Randomized trial of neoadjuvant cisplatin, vincristine, bleomycin, and radical hysterectomy versus radiation therapy for bulky stage IB and IIA cervical cancer

PURPOSE

To compare the efficacy of neoadjuvant chemotherapy (NAC) followed by radical hysterectomy with that of radiotherapy (R/T) for bulky early-stage cervical cancer.

PATIENTS AND METHODS

Women with previously untreated bulky (primary tumor >/= 4 cm) stage IB or IIA non-small-cell carcinoma of the uterine cervix were randomly assigned to receive either cisplatin 50 mg/m(2) and vincristine 1 mg/m(2) for 1 day and bleomycin 25 mg/m(2) for 3 days for three cycles followed by radical hysterectomy (NAC arm) or receive primary pelvic radiotherapy only (R/T arm). The ratio of patient allocation was 6:4 for the NAC and R/T arms. Women with enlarged para-aortic lymph nodes on image study were ineligible unless results of cytologic or histologic studies were negative.

RESULTS

Of the 124 eligible patients, 68 in the NAC arm and 52 in the R/T arm could be evaluated. The median duration of follow-up was 39 months. Thirty-one percent of patients in the NAC arm and 27% in the R/T arm had relapse or persistent diseases after treatment, and 21% in each group died of disease. Estimated cumulative survival rates at 2 years were 81% for the NAC arm and 84% for the R/T arm; the 5-year rates were 70% and 61%, respectively. There were no significant differences in disease-free survival and overall survival.

CONCLUSION

NAC followed by radical hysterectomy and primary R/T showed similar efficacy for bulky stage IB or IIA cervical cancer. Further study to identify patient subgroups better suited for either treatment modality and to evaluate the concurrent use of cisplatin and radiation without routine hysterectomy is necessary.

The usefulness of cystoscopy in the staging of cervical cancer

OBJECTIVE

The aim of this study was to clarify the usefulness of cystoscopy in the staging of cervical cancer and to evaluate the clinical indications for performing ureteric catheterization to rule out ureteral obstruction in cervical cancer.

METHODS

Both rigid cystoscopy and CT were performed before treatment in patients with cervical cancer of FIGO stage IB or greater. Cystoscopically directed biopsy specimens were taken from all areas in the bladder which were suspected of cancerous development. If a jet of urine spurting from each ureteral orifice was not found, a ureteric catheter was inserted into the orifice to rule out ureteral obstruction. The cystoscopic findings were compared with a CT examination.

RESULTS

A total of 100 patients were included in the study (mean age 59 years). There were 30 stage IB cancers, 20 stage IIA, 17 stage IIB, 5 stage IIIA, 18 stage IIIB, and 10 stage IV. A total of 90 patients had squamous cell carcinomas and 10 had adenocarcinomas. Cystoscopy identified 8 patients with bladder invasion including 1 stage IIIA, 2 stage IIIB, and 5 stage IV. All of these patients had CT indication of possible invasion. CT indication of possible invasion was proved to be false by cystoscopy in 2 patients. Both the sensitivity and the negative predictive value of CT for bladder invasion were 100%. Of the 14 patients in whom ureteral obstruction was diagnosed by ureteric catheterization, 11 cases were indicated by CT scan, but for the other 3 patients CT found no significant ureteral obstruction.

CONCLUSIONS

The results of this study suggest that cystoscopy is indicated only in cervical cancer patients for whom CT examination indicates possible bladder invasion. In addition, the results suggest that placement of ureteric catheterization using cystoscopy to rule out ureteral obstruction is not indicated in the staging of cervical cancer.

Regulation and functions of c-Jun N-terminal kinase/stress-activated protein kinase

The cell uses a complex signal transduction network both to respond to changes in its microenvironment and to integrate all of its intracellular signals. Actions of various signals in the cellular signal transduction network converge at the mitogen-activated protein kinase (MAPK) cascades, which lead to and activate transcription factors in the nucleus and other effectors throughout the cell. Extracellular signal-regulated kinases (ERKs), c-Jun N-terminal kinases/stress-activated protein kinases (JNK/SAPK), and p38 are some of the better characterized members of the MAPK family. Unlike ERK mainly responding to mitogens, JNK/SAPK was originally identified as a stress-related kinase and it has been extensively demonstrated to be associated with apoptosis. However, recent studies have further indicated that JNK/SAPK also has many functions other than the promotion of apoptosis. The repertoire of the JNK/SAPK pathway is wide-ranging, and its functions can vary, and even oppose each other, depending on the cell types and stimuli. It remains a challenge for biomedical scientists to elucidate the distinct role of JNK/SAPK in each model system.

Successful treatment of recurrent pelvic desmoid tumour with tamoxifen: case report

The case report of a young woman with recurrent pelvic desmoid tumour successfully treated with tamoxifen is described. The desmoid tumour recurred within 6 months after the initial exploratory laparotomy. Tamoxifen therapy led to complete relief of ascites within 2 months and complete tumour regression by the end of the fourth month, and the patient has remained stable for 6 years. Without sacrificing pelvic organs or major vessels and preserving reproductive ability, tamoxifen should be considered as the first drug of choice in such a recurrent condition.

Laparoscopic extraperitoneal sacrospinous suspension for vaginal vault prolapse

BACKGROUND

A new laparoscopic sacrospinous suspension procedure is described for the correction of vaginal vault prolapse using an extraperitoneal approach. This is the first report in the literature of the extraperitoneal approach.

METHODS

We reviewed 12 women who had been treated in our hospital using this technique because of vaginal vault prolapse. These women had undergone hysterectomies (10 abdominal; 2 vaginal) between 5 and 22 years previously (mean, 12 years). After pre-laparoscopic preparation, a 10-mm trocar with a 10-mm zero-degree telescope was placed into the Retzius space. Using a direct air-distended method with a 20 mmHg insufflation pressure, Retzius and para-rectal spaces were created. The sacrospinous ligament could be easily identified and confirmed. A permanent suture was then inserted from the sacrospinous ligament to the vaginal vault to ensure that there was no space in between.

RESULTS

This procedure was followed for all 12 patients. There were no major complications during surgery. Eleven women had no recurrence of vaginal vault prolapse during a follow-up period of 1 to 3 years (mean, 2.2 years). One patient developed recurrent vaginal vault prolapse; however, she subsequently underwent a successful colposacropexy by laparoscopy 23 months after the initial surgery.

CONCLUSION

We modified the traditional sacrospinous fixation laparoscopically, following principles to restore the correct anatomic position of the vault. Laparoscopic extraperitoneal sacrospinous suspension can eliminate the procedure of opening and closing the peritoneum and avoid interference with the intestine during surgery. It can be used as an alternative to traditional genital suspension surgeries.

Comparison the efficacy of laparosonic coagulating shears and electrosurgery in laparoscopically assisted vaginal hysterectomy: preliminary results

OBJECTIVE

To compare the safety and effectiveness of laparosonic coagulating shears (LCS) and electrosurgery for use in laparoscopically assisted vaginal hysterectomy (LAVH).

STUDY DESIGN

In this prospective study, patients undergoing LAVH performed by one of the authors from October 1997 to January 1998 were assigned at random to the electrosurgery group (n = 20) or the LCS group (n = 20). Procedures performed with LCS or electrosurgery included coagulation and separation of infundibulopelvic or utero-ovarian round ligaments, vesico-uterine-visceral peritoneal fold dissection, and anterior and posterior colpotomy. Outcome measures were operative time, blood loss, decrease in hemoglobin values, and length of hospitalization.

RESULTS

The mean operative time (90+/-22.9 min versus 80.3+/-17.1 min, P = 0.391), blood loss (308+/-167 ml versus 250+/-104 ml, P = 0.11), and hemoglobin decrease (1.57+/-0.769 mg/dl versus 1.36+/-0.886 mg/dl, P = 0.55) were slightly greater in the LCS group than in the electrosurgery group, although these differences were not statistically significant. The length of hospital stay was similar in the two groups (5 days). No patients developed serious complications related to electrosurgery or LCS.

CONCLUSION

Our findings indicate that LCS is as safe and effective as electrosurgery, and may offer an alternative option for patients undergoing LAVH.

Elevation of insulin-like growth factor-binding protein-1 mRNA expression following hormone replacement therapy

The purpose of this study was to investigate the possible regulatory roles of insulin-like growth factors (IGF) and IGF binding protein-1 (IGFBP-1) on postmenopausal endometrium in women undergoing hormone replacement therapy (HRT). Endometrial tissues and blood samples were collected from 25 postmenopausal women with abnormal uterine bleeding before and after HRT. As a control, blood and endometrial samples were also obtained at mid-luteal phase (days 18-23 of the menstrual cycle) from 10 women with benign uterine leiomyoma during surgical intervention. Expression of mRNA for IGF-I, IGF-II, type 1-IGF receptor, IGFBP-1, oestrogen receptor (ER) and progesterone receptor (PR) in the endometrium was explored by a semiquantitative reverse transcription-polymerase chain reaction (RT-PCR). Serum concentrations of IGFBP-1, oestradiol, progesterone, follicle stimulating hormone (FSH) and sex hormone-binding globulin (SHBG) were also determined. In the endometrium obtained from postmenopausal women with abnormal uterine bleeding (before HRT), expression of IGFBP-1 was undetectable, whereas PR expression was abundant. HRT significantly up-regulated expression of IGFBP-1 but down-regulated PR. Moderate expression of IGF-I, IGF-II, type 1-IGF receptor and ER was identified in the postmenopausal endometrium before HRT. HRT significantly down-regulated IGF-I, up-regulated IGF-II, but had no effects on expression of type 1-IGF receptor and ER. In conclusion, up-regulation of IGFBP-1 collaboratively with down-regulation of IGF-I may account for the protective effect of progesterone in HRT on the endometrium.

A huge 6.2 kilogram uterine myoma coinciding with omental leiomyosarcoma: case report

Surgery for massive abdominal tumors is both interesting and challenging. We present a case involving a multiple uterine myoma weighing 6.2 Kg which coincided with omental leiomyosarcoma. To our knowledge, this is the first report of this type of condition in the English literature. A 44-year-old nulliparous woman had suffered from abdominal pain for a long time. A huge abdominal mass was palpated on physical examination. Computed tomography scanning revealed a huge pelvic-abdominal mass with the possibility of small bowel loops invaded by the mass. A 6-cm omental mass was incidentally found during the subsequent hysterectomy procedure. Perforation of the urinary bladder occurred during the dissection of adhesion. Resection of the omental mass, wide wedge resection of the invaded small bowel, primary repair of the bladder, and hysterectomy were performed. The final pathologic diagnosis was uterine leiomyomata with omental leiomyosarcoma. The patient returned home on postoperative day 14 and was well at the 18-month follow-up examination. The challenge of these tumors lies in their proper diagnosis and surgical management. More case reports and follow-up studies are needed to confirm the efficacy of their management.

Endoscopic management of injured bowel using the automatic stapler

Bowel injury is a rare but potentially fatal complication of laparoscopy if it is unrecognized at the time of the procedure. Once a bowel injury is identified, it must be repaired by either laparoscopy or laparotomy. The Endo GIA 30 stapler is effective for achieving large-vessel hemostasis and facilitating laparoscopic procedures, and is reported safe for laparoscopic hysterectomy. It was used successfully in two women to repair extensive bowel injuries.

Maternal serum screening for down syndrome in pregnancies conceived by intra-uterine insemination

The purpose of our study was to assess the influence of intra-uterine insemination (IUI) on the results of maternal serum Down syndrome screening. 43 women with IUI pregnancies and 4507 healthy women who conceived were studied. Ovulation in IUI pregnancies was induced by clomiphene and/or human menopausal gonadotrophin (hMG). Maternal serum levels of free beta-human chorionic gonadotrophin (hCG) and alpha-fetoprotein (AFP) were measured for Down syndrome screening. It was considered screen-positive when the risk of Down syndrome was 1 in 270 or greater in the second trimester. The value of maternal serum AFP was significantly lower in the IUI group (median=0.760 MoM) than in the control group (median=1.050 MoM). However, the value of free beta-hCG was not significantly different between the two groups. The positive rate of maternal serum Down syndrome in IUI pregnancies was similar to that of the control group. Our results indicate that IUI pregnancy may be associated with a lower level of AFP, although the mechanism for this difference remains unknown.

Clinical management of a quadruplet pregnancy combining a triplet pregnancy with a classical hydatidiform mole: case report and review of literature

A 28-year-old Taiwanese woman who had received ovulation induction by clomiphene citrate (CC), follicular-stimulating hormone (FSH), and human chorionic gonadotrophin (hCG) treatment was diagnosed with a quadruplet pregnancy containing a hydatidiform mole and three fetuses at nine weeks' gestation. Expectant management failed to achieve any viable neonate due to massive antepartum haemorrhage and preterm delivery at 25 weeks' gestation. Five other cases previously reported involving quadruplets or triplets with a complete hydatidiform mole and two or three fetuses are reviewed. All cases ended as premature non-viable fetuses. Analysis of the clinical features, management, and outcome both in our patient and these reports suggest that more efficacious treatment planning, such as selective feticide, should be considered in order to improve the likelihood of attaining an advanced gestational age for a single fetus.

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.

Prenatal diagnosis of trisomy 20 mosaicism by maternal serum screening for Down syndrome

We report two cases of prenatally diagnosed trisomy 20 mosaicism associated with positive Down syndrome screening at 16 weeks' gestation. Both infants exhibited normal growth and mental development. These cases suggest that the multiple-marker screening test may play an important role in prenatal detection and diagnosis of chromosomal anomalies in addition to Down syndrome.