Anil B. Pinto

Successful in vitro fertilization pregnancy after conservative management of endometrial cancer

OBJECTIVE To report a successful IVF pregnancy in an infertile couple after conservative treatment of endometrial cancer. DESIGN Case report and literature review. SETTING University teaching hospital. PATIENT(S) A 29-year-old infertile white woman. MAIN OUTCOME MEASURE(S) Successful pregnancy after conservative management of endometrial cancer. INTERVENTION(S) Grade 1 endometrial adenocarcinoma diagnosed at hysteroscopy, followed by dilatation and curettage (D&C). On follow-up D&C, pathologic examination was normal after high-dose progesterone therapy. The patient subsequently underwent an IVF cycle with transfer of three blastocysts. RESULT(S) The patient delivered triplets by cesarean section. Laparoscopic-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy was then done. No residual endometrial cancer was evident in the hysterectomy specimen, but a 1.1-cm cystic mixed endometrioid and clear cell-type adenocarcinoma was discovered in the left ovary. The patient is doing well after 3 cycles of chemotherapy; her CA-125 level is normal. The triplets are also doing well. CONCLUSION(S) In carefully chosen situations, deferring surgery in infertile patients with endometrial cancer may be a viable option permitting subsequent successful pregnancy.

Reduction of ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries

OBJECTIVE To report a rare case of unilateral ovarian torsion 1 week after embryo transfer in a patient with bilateral hyperstimulated ovaries. DESIGN Case report and literature review. SETTING Reproductive Endocrine division in a university teaching hospital. PATIENT(S) Infertility patients undergoing IVF-ET. INTERVENTION(S) Laparoscopic reduction of adnexa 1 week after ET. MAIN OUTCOME MEASURE(S) Successful preservation of the affected adnexa. RESULT(S) Delivery of 3.324 kg male infant with preservation of the affected ovary. CONCLUSION(S) Untwisting of the affected ovary at laparoscopy without aspiration reduction of cystic masses is appropriate. The outcome of the pregnancy (even very early) in patients with torsion of the adnexa may be favorable after a laparoscopic unwinding of the affected adnexa.

Intranasal hormone replacement therapy.

Although the optimal route of delivery for hormone replacement therapy has not yet been determined, desirable qualities would include good efficacy, easy administration, minimal side effects, and optimal therapeutic profile. This would potentially serve to improve patient compliance and satisfaction. The intranasal route has been evaluated for the administration of menopausal hormones and seems to fulfill these requirements. The intranasal route would also seem to be a viable alternative for drugs that are poorly absorbed after ingestion by avoiding hepatic first-pass elimination. The intranasal route is, therefore, innovative for the delivery of natural sex steroids in postmenopausal women receiving hormone replacement therapy. Early studies demonstrate that it is safe, effective, and acceptable to postmenopausal women. In addition, the nasal administration of a combination of estradiol and progesterone would seem to be an attractive way to deliver hormones to nonhysterectomized postmenopausal women. Providing alternative routes of administration may also enhance compliance.

Atypical squamous cells of undetermined significance in girls and women.

OBJECTIVE: To estimate the outcome of adolescents with atypical squamous cells of undetermined significance (ASC-US) on cytology. METHODS: A review of ASC-US cytology in girls and women aged 10–19 years between 1995 and 1999 was performed. The cytologic and histologic follow-up of each patient was evaluated. The outcome was recorded as the most significant (highest grade) subsequent cervical smear or biopsy. RESULTS: Overall, 535 of 7,897 (6.8%) cervical cytologic specimens were reported as ASC-US. The study group consisted of 398 patients for whom pathologic follow-up was available. The mean duration of follow-up was 19 months. Follow-up consisted of repeat cytology in 251 (63%) patients and colposcopy with cervical biopsies and/or endocervical curettage in 147 (37%) of the adolescents. Two hundred fifty-three (64%) adolescents had no pathologic abnormalities on follow-up. Persistent ASC-US was identified in 65 (16%), low-grade squamous intraepithelial lesions/cervical intraepithelial neoplasia (CIN) 1 was found in 44 (11%) and high-grade squamous intraepithelial lesions/CIN 2 or 3 occurred in 36 (9%) of the adolescents. No cases of invasive carcinoma were found. CONCLUSIONS: Among adolescents with ASC-US, the rate of squamous intraepithelial lesions/CIN is similar to that of adults. Although the optimal management of ASC-US in adolescents is unknown, these patients warrant close follow-up. LEVEL OF EVIDENCE: III

Pregnancy outcomes after fallopian tube recanalization: Oil-based versus water-soluble contrast agents

PURPOSE To determine the pregnancy outcomes in patients undergoing fallopian tube recanalization (FTR) with use of oil-based versus water-soluble contrast agents. MATERIALS AND METHODS Ninety-three patients with unilateral or bilateral proximal tubal occlusion confirmed by hysterosalpingography or laparoscopy underwent FTR with use of water-soluble contrast material alone (n = 50) or also had an oil-based agent injected into each tube after recanalization (n = 43). Pregnancy rates and outcomes of the two groups were studied retrospectively. RESULTS With respect to differences between groups, only the body mass index proved to be a significant predictor (oil, 28.4; water, 24.7; P =.008). Mean age, duration of infertility, type of infertility, and initial diagnosis were comparable. There was a weak trend toward a higher pregnancy rate in the oil-based contrast material group, but it was not significant (P =.64). The average time to pregnancy was 4.4 months with use of oil-based contrast material, compared to 7.7 months with use of only water-soluble contrast material (P =.03). CONCLUSION The use of an oil-based agent had little effect on the rate of conception, but time to conception was reduced by more than 3 months.

Clinical manifestations and treatment of gout

Abstract Gout results from the deposition of urate crystals in a variety of soft tissues throughout the body. Currently over half a million American women suffer from the disorder. Disease manifestations include painful attacks of acute arthritis as well as chronic arthritis with deposition of uric acid crystals known as tophi. The disorder is often overlooked and misdiagnosed as another form of arthritis. Multiple drugs are now available to treat the acute pain of gouty arthritis, as well as to help reduce the long-term complications of gout and chronic hyperuricemia.

Treatment of uterine fibroids

Abstract Uterine leiomyomas are benign tumors that arise from myometrial smooth muscle cells. They are present in 20–25% of women of reproductive age. These benign tumors are generally firm, well circumscribed and composed of smooth muscle cells in an interdigitating pattern separated by fibrous connective tissue. Fibroids are more common in black women, and on an average, 50% of all laparotomies for a pelvic pathology are performed for myomas. If asymptomatic, they can generally be managed expectantly, but 75% do have symptoms. 1 , 2 Up to one third of patients experience abnormal uterine bleeding and/or abdominal or pelvic pain. 3 They have also been associated with both impaired fertility and poor obstetric outcome. The incidence of malignancy is small, and has been reported to be 0.29% in a study of 33,000 pathology specimens. 1 Patients presenting with infertility and with abnormal uterine bleeding have a higher incidence of uterine fibroids. Possible symptoms of uterine fibroids include bleeding, pressure, pelvic pain, recurrent pregnancy loss, bladder or bowel symptoms, and infertility. Generally, uterine myomas arise from a single smooth muscle cell clone, which proliferates beyond normal control mechanisms. Surgical treatment options include laparotomy with myomectomy, hysteroscopic myoma resection, or laparoscopic myomectomy. More recently, treatment of submucosal myomas has been managed almost exclusively by operative hysteroscopy. The purpose of this manuscript is to briefly discuss symptoms and diagnosis but to primarily focus on treatment.

The additional benefits of hormone replacement therapy

Abstract The menopause is a time of significant physiological change in the lives of women. In addition to the multiple hormonal changes and symptoms of menopause, aging women are at increased risk for serious medical illness. The benefits of estrogen replacement therapy for the preservation of bone and decreased fracture incidence, improvement of lipid profile, and prevention of cardiovascular disease are well known. In addition, recent research has revealed a potential role for estrogen therapy in the prevention of colon cancer, Alzheimer’s disease, and macular degeneration. Large prospective trials have demonstrated a significant reduction in the development of colon cancer among current users of estrogen replacement therapy compared with in non-users. Alzheimer’s disease is a significant health problem that affects older adults and therefore, postmenopausal women. A fair number of observational studies have suggested that estrogen may play a role in the prevention of Alzheimer’s disease. Additional studies have suggested that estrogen may improve cognitive function among menopausal women without dementia, but it appears to have little effect on cognitive function in women with established Alzheimer’s disease-related dementia. Macular degeneration is a leading cause of blindness among menopausal women. Several studies have suggested that the use of estrogen may reduce the incidence of macular degeneration compared with non-users. Epidemiological studies have shown a potential benefit of estrogen in the areas of colon cancer, Alzheimer’s disease, and macular degeneration. However, prospective, randomized trials are necessary to definitively answer these questions.

Pregnancy outcomes after fallopian tube recanalization (FTR): oil-based vs. water-soluble contrast agents

RESULTS: With respect to differences between groups, only the body mass index proved to be a significant predictor (oil, 28.4; water, 24.7; P .008). Mean age, duration of infertility, type of infertility, and initial diagnosis were comparable. There was a weak trend toward a higher pregnancy rate in the oil-based contrast material group, but it was not significant (P .64). The average time to pregnancy was 4.4 months with use of oil-based contrast material, compared to 7.7 months with use of only water-soluble contrast material (P .03).

The role of bilateral ovarian diathermy by KTP laser in the oligoovulatory patient

Objective: To assess the efficacy of ovarian diathermy in women who respond poorly to clomiphene citrate (CC). Methods: Retrospective analysis of patients who failed to respond to 200 mg of CC and subsquently were treated with KTP laser bilateral ovarian diathermy. Twenty-one patients with a total of 288 cycles were included. Results: The study patients had a mean age of 29.8 ± 5.0 years (n = 21) and a mean body mass index of 35.1 ± 10.0 (n = 20). Each patient had a mean of 10.1 ± 5.1 cycles of CC prediathermy and 3.6 ± 3.7 cycles of CC postdiathermy. For all CC dosages, and including two spontaneous cycles after diathermy that resulted in two pregnancies, there was a significant difference in the number of responsive cycles postdiathermy (24% versus 66%, P = 0.0003). Conception rates per cycle also were significantly different (3% versus 17%, P = 0.0029). Spontaneous abortion rates per pregnancy were higher prediathermy (4/6 versus 2/12, P insignificant). Conclusions: Oligoovulatory patients who respond poorly to CC therapy may benefit from bilateral ovarian diathermy using the KTP laser. A positive midcycle urinary luteinizing hormone test, sonographic evidence of follicular development to 18mm or greater, a midluteal phase serum progesterone of 10ng/mL or greater, and/or spontaneous menses (only in patients with oligomenorrhea) were considered positive responses to CC.