Chen-Yu Huang

Fertility outcome of infertile women with adenomyosis treated with the combination of a conservative microsurgical technique and GnRH agonist: long-term follow-up in a series of nine patients.

OBJECTIVE This paper reports the long-term follow-up (62-83 months) of women with unexplained subfertility secondary to severe adenomyosis treated with the combination of conservative surgery and gonadotropin releasing hormone agonist (GnRH agonist) therapy. MATERIALS AND METHODS A retrospective study included nine patients with a history of > 3 years of unexplained infertility who had extensive uterine adenomyosis. These nine couples were diagnosed with unexplained infertility after excluding other possible causes, such as the male factor, ovulation disorders, structural abnormality, and infections. All were essentially normal except for presumed uterine adenomyosis and elevated serum levels of CA125. All underwent a careful excision of the adenomyosis tissue using a microsurgical technique, and then a six-month course of GnRH agonist therapy. The outcome evaluations included serum level of CA125, degree of dysmenorrhea, and rate of spontaneous pregnancy. RESULTS Postoperative follow-up showed that the severity of dysmenorrhea was significantly improved. The improvement scale was positively correlated with a decline in the serum level of CA125. A postoperative serum CA125 decreased to less than 10.00 IU/mL predicted well the spontaneous pregnancy rate, especially during the therapy. In the end, only two women became pregnant and finally delivered viable babies in this study. CONCLUSIONS Although the combination of careful conservative surgery and GnRH agonist therapy might provide some benefits in patients with unexplained infertility and presumed severe adenomyosis, two-thirds of the patients still failed to become pregnant. The postoperative serum level of CA125 could predict the future pregnancy rate.

Anti-Mullerian hormone serum level as a predictive marker of ovarian function in Taiwanese women

Background: Anti‐Mullerian hormone (AMH), which is secreted by preantral and small antral follicles, has been found to be a valuable marker of ovarian reserve. The purpose of this study was to determine age‐related changes in AMH levels that occur in Taiwanese women and to determine whether measuring AMH is a highly sensitive and specific tool for diagnosing polycystic ovarian syndrome (PCOS) in Taiwanese women. Methods: A group of 59 healthy, fertile, regularly cycling women, a second group of seven patients with premature ovarian failure or menopause, and a third group of 45 PCOS patients were enrolled. Serum AMH concentrations were measured using an enzyme‐linked immunosorbent assay. Results: AMH levels in healthy fertile women with regular menstrual cycles demonstrated an age‐related decline, with a rapid drop between 30–40 years of age that was followed by a slow decrease after 40 years old. All patients with premature ovarian failure and menopause had undetectable AMH levels. AMH levels in PCOS patients were found to be significantly higher than those measured in healthy fertile controls. The sensitivity and specificity of AMH for detecting PCOS in patients aged 29–38 years were calculated to be 74% and 79%, respectively, using an AMH cut‐off value of 3.5 ng/mL. Conclusion: Here, we provide data on Taiwanese women that demonstrate age‐related decline in AMH levels and establish an AMH‐based method for detecting PCOS, which may be used as reference data for future AMH studies on Taiwanese women.

Women with endometriosis have higher comorbidities: Analysis of domestic data in Taiwan.

Abstract Endometriosis, defined by the presence of viable extrauterine endometrial glands and stroma, can grow or bleed cyclically, and possesses characteristics including a destructive, invasive, and metastatic nature. Since endometriosis may result in pelvic inflammation, adhesion, chronic pain, and infertility, and can progress to biologically malignant tumors, it is a long‐term major health issue in women of reproductive age. In this review, we analyze the Taiwan domestic research addressing associations between endometriosis and other diseases. Concerning malignant tumors, we identified four studies on the links between endometriosis and ovarian cancer, one on breast cancer, two on endometrial cancer, one on colorectal cancer, and one on other malignancies, as well as one on associations between endometriosis and irritable bowel syndrome, one on links with migraine headache, three on links with pelvic inflammatory diseases, four on links with infertility, four on links with obesity, four on links with chronic liver disease, four on links with rheumatoid arthritis, four on links with chronic renal disease, five on links with diabetes mellitus, and five on links with cardiovascular diseases (hypertension, hyperlipidemia, etc.). The data available to date support that women with endometriosis might be at risk of some chronic illnesses and certain malignancies, although we consider the evidence for some comorbidities to be of low quality, for example, the association between colon cancer and adenomyosis/endometriosis. We still believe that the risk of comorbidity might be higher in women with endometriosis than that we supposed before. More research is needed to determine whether women with endometriosis are really at risk of these comorbidities.

Uterine sarcoma Part II—Uterine endometrial stromal sarcoma: The TAG systematic review

Endometrial stromal tumors are rare uterine tumors (<1%). Four main categories include endometrial stromal nodule, low-grade endometrial stromal sarcoma (LG-ESS), high-grade endometrial stromal sarcoma (HG-ESS), and uterine undifferentiated sarcoma (UUS). This review is a series of articles discussing the uterine sarcomas. LG-ESS, a hormone-dependent tumor harboring chromosomal rearrangement, is an indolent tumor with a favorable prognosis, but characterized by late recurrences even in patients with Stage I disease, suggesting the requirement of a long-term follow-up. Patients with HG-ESS, based on the identification of YWHAE-NUTM2A/B (YWHAE-FAM22A/B) gene fusion, typically present with advanced stage diseases and frequently have recurrences, usually within a few years after initial surgery. UUS is, a high-grade sarcoma, extremely rare, lacking a specific line of differentiation, which is a diagnosis of exclusion (the wastebasket category, which fails to fulfill the morphological and immunohistochemical criteria of translocation-positive ESS). Surgery is the main strategy in the management of uterine sarcoma. Due to rarity, complex biological characteristics, and unknown etiology and risk factors of uterine sarcomas, the role of adjuvant therapy is not clear. Only LG-ESS might respond to progestins or aromatase inhibitors.

Parasitic peritoneal leiomyomatosis mimicking intra-abdominal abscess with hematoma.

A 43-year-old sexually-naive female, a case of primary transsexualism, female to male, was treated with stage I sexual reassignment surgery. This included vaginal hysterectomy, bilateral salpingo-oophorectomy, vaginectomy, neourethra prelamination, and bilateral reduction mammoplasty at the tertiary medical center. Preoperative evaluation was unremarkable, however, no image study for the uterus (e.g., ultrasound) was done. A very large uterus was extracted and removed blindly through the vagina. Final pathology showed an 18 � 14 � 9c m 3 uterus containing the 10 � 8 � 7c m 3 cellular leiomyoma. Postoperative recovery was uneventful. Fourteen days after the operation, the patient suffered from intermittent chills accompanied with lower abdominal pain and a spiking fever up to 39.5 � C. Physical examination revealed significant tenderness in the right lower quadrant area, but with an absence of peritoneal signs or rebounding pain. Laboratory data revealed increased white cell counts (WBC ¼ 13800/mm 3 )

Uterine sarcoma Part I—Uterine leiomyosarcoma: The Topic Advisory Group systematic review

Uterine sarcomas account for 3-7% of all uterine cancers. Because of their rarity, unknown etiology, and highly divergent genetic aberration, there is a lack of consensus on risk factors for occurrence and predictive poor outcomes as well as optimal therapeutic choices. Tumor types according to the World Health Organization classification include leiomyosarcoma, endometrial stroma sarcoma, and undifferentiated sarcoma. Staging is done using the 2014 Federation International Gynecology and Obstetrics and 2010 American Joint Committee on Cancer tumor, lymph node, and metastases systems. Tumor grade can be classified based on the French Federation of Cancer Centers Sarcoma Group system or the Broders system that incorporates tumor differentiation, mitotic count, and tumor necrosis. This review is a series of articles discussing uterine sarcoma, and this is Part I, which focuses on one of the subtypes of uterine sarcomas-uterine leiomyosarcoma. The clinical characteristics, diagnosis, outcome, and recent advances are summarized in this article.

Mean grey value is lower in endometriomas: Differentiating a hypoechogenic adnexal cyst by 3-dimensional power Doppler ultrasound—A preliminary study

Background: To assess parameters of 3‐dimensional power Doppler ultrasound in differentiating an endometrioma from other hypoechogenic adnexal cysts. Methods: We collected 58 patients with classic‐appearing endometriomas (homogeneous hypoechogenic adnexal cysts with round shapes) on a 2‐dimensional conventional sonography. The serum level of CA‐125, parameters of 3‐dimensional pelvic ultrasound including the volume of the cyst, the mean grey value (MGV), and three vascular indices: vascularization index, flow index, and vascularization flow index, were measured and then, after surgical intervention, were compared between the group with histologically proven endometriomas and the group with other histological diagnoses. Results: In the chocolate cyst group, the parity was significantly lower (0.68 ± 0.17, p = 0.012). The MGV and lesion volume of histologically proven endometriomas were significantly lower (14.78 ± 0.7; 118.34 ± 15.5) than those of other hypoechogenic benign adnexal cysts (17.17 ± 0.74; 227.18 ± 47.46), and the p values were 0.038 and 0.041, respectively. No differences in vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were found between the two groups. No relationship between lesion volume and MGV in the two groups, either (p = 0.127 and 0.353). We also found little correlation between CA‐125 and the volume of a histologically proven endometrioma as well as between CA‐125 and its MGV. Conclusion: MGV might be useful to differentiate an endometrioma from other homogeneous hypoechogenic adnexal cysts.

Uterine sarcoma part III—Targeted therapy: The Taiwan Association of Gynecology (TAG) systematic review

Uterine sarcoma is a very aggressive and highly lethal disease. Even after a comprehensive staging surgery or en block cytoreduction surgery followed by multimodality therapy (often chemotherapy and/or radiation therapy), many patients relapse or present with distant metastases, and finally die of diseases. The worst outcome of uterine sarcomas is partly because of their rarity, unknown etiology, and highly divergent genetic aberration. Uterine sarcomas are often classified into four distinct subtypes, including uterine leiomyosarcoma, low-grade uterine endometrial stromal sarcoma, high-grade uterine endometrial stromal sarcoma, and undifferentiated uterine sarcoma. Currently, evidence from tumor biology found that these tumors showed alternation and/or mutation of genomes and the intracellular signal pathway. In addition, some preclinical studies showed promising results for targeting receptor tyrosine kinase signaling, phosphatidylinositol 3-kinase/AKT/mammalian target of rapamycin pathway, various kinds of growth factor pathways, Wnt/beta-catenin signaling pathway, transforming growth factor β/bone morphogenetic protein signal pathway, aurora kinase A, MDM2 proto-oncogene, histone deacetylases, sex hormone receptors, certain types of oncoproteins, and/or loss of tumor suppressor genes. The current review is attempted to summarize the recurrent advance of targeted therapy for uterine sarcomas.

Impact of hysterosalpingography after operative treatment for ectopic pregnancy in Taiwan: A 16-year Nationwide Population-Based Analysis

Abstract By retrieving records from Taiwans National Health Insurance (NHI) systems database, the current study aimed to investigate the impacts of hysterosalpingography (HSG) to patients after ectopic pregnancy (EP) operations in Taiwan. In this retrospective cohort study, insurance claims data from 1997 to 2013, derived from a cohort of 1 million people randomly sampled to represent all NHI beneficiaries, were analyzed. Patients after ectopic pregnancy (EP) operations were identified via the inclusion of the corresponding NHI procedure codes. We further divided the patients into 2 groups by whether received subsequent HSG, EP-HSG, and EP-no-HSG. Patients with history of previous pregnancies (PP) and subsequent HSG were grouped as PP-HSG. We sought to evaluate the following pregnancies (FP) rate, interval to FP in EP-HSG compared with that in EP-no-HSG, and PP-HSG. EP-HSG had significantly higher FP rate odds ratio than EP-no-HSG (OR, 1.64; 95% CI, 1.24–2.16, P < .001). EP-HSG had lower FP rate odds ratio than that in PP-HSG, but no significant difference (33.1% vs 34.6%, P  =  .654). The INTERVAL(HSG-FP) in EP-HSG was no significantly different from that in PP-HSG (843.34 ± 82 days vs 644.72 ± 24.30 days, P  =  .077). There was significant positive correlation between FP after EP and number of HSG (r  =  0.070**, P < .001). There were significant negative correlation between FP and EP age (r  =  −0.270**, P < .001), FP and INTERVAL(EP-HSG) (r  =  −0.212**, P  =  .001). The multivariate analysis showed that INTERVAL(EP-HSG) less than 1 year is the predictor factor of INTERVAL(EP-FP) (hazard ratio: 1.422; 95% CI: 1.130–1.788; P = .003). It was evident that the longer the INTERVAL(EP-HSG), the lower the FP rate odds ratio; and the older the EP age, the lower the FP rate odds ratio. (OR, 95% CI; >1 year: 0.59, 0.41–0.86; >2 year: 0.42, 0.32–0.55; >25 years old: 0.47, 0.38–0.57; >30 years old: 0.29, 0.24–0.35; >35 years old: 0.12, 0.08–0.18, all P < .001). Receiving HSG after EP, short INTERVAL(EP-HSG), EP age less than 30 years old, had significant positive impacts on the FP. We encourage shortening the INTERVAL(EP-HSG), and the counseling of women on the most appropriate way to conceive thereafter.

The benefit of individualized low-dose hCG support for high responders in GnRHa-triggered IVF/ICSI cycles.

Background To assess the pregnancy outcome and ovarian hyperstimulation syndrome (OHSS) incidence in high responders receiving gonadotropin‐releasing hormone agonist (GnRHa) trigger plus individualized support of low‐dose human chorionic gonadotropin (hCG). Such support includes 500–1000 IU hCG given at trigger and, if serum estradiol (E2) dropped to below 800 pg/mL before the 6th day after oocyte retrieval, an additional rescue dose of 300 IU hCG. Methods This was a retrospective study of potential high responders aged from 28 years to 40 years at a tertiary fertility center in Taiwan. By means of chart review, we assessed the pregnancy outcome and OHSS incidence in high responders receiving GnRHa trigger plus individualized low‐dose hCG support. The main outcomes were measured by ongoing pregnancy rate and OHSS incidence (SPSS), in which statistical significance was determined by Chi‐square test. Results Moderate to severe OHSS did not develop in any patient receiving GnRHa trigger plus individualized low‐dose hCG support. In fact, a satisfactory ongoing pregnancy rate (46.9%) was noted in patients receiving GnRHa trigger plus individualized low‐dose hCG support. Conclusion Our study suggested that GnRHa trigger combined with individualized low‐dose hCG support appears to be a safe approach with a satisfactory pregnancy outcome.