Chii-Shinn Shiau

Effectiveness of ultrasound-guided aspiration and sclerotherapy with 95% ethanol for treatment of recurrent ovarian endometriomas

OBJECTIVE To evaluate the effectiveness of transvaginal ultrasound aspiration and ethanol sclerotherapy in patients with recurrent ovarian endometriomas. DESIGN Retrospective study. SETTING Teaching hospital affiliated with Chang Gung University, Taipei. PATIENT(S) Patients (n = 108) with recurrent ovarian endometriomas >or=3 cm. INTERVENTION(S) Preoperative evaluation of previous pathology, midcycle serum CA-125 level, and color Doppler ultrasonography to exclude possibility of malignancies. After aspiration, sclerotherapy with 95% ethanol irrigation of the cystic cavity was performed (group 1, n = 78, 0-10 minutes of retention; group 2, n = 30, ethanol left in situ [retention]). MAIN OUTCOME MEASURE(S) Ultrasonography was performed at 3, 6, 9, and 12 months to determine persistence and size of cysts and the number of antral follicles. Pelvic pain score was also determined at those time points. RESULT(S) The 1-year recurrence rate for group 2 patients was significantly lower than for group 1 patients (13.3% vs. 32.1%). Antral follicle count was increased and pain score was decreased in both groups to a similar level. No significant change in CA-125 was observed. CONCLUSION(S) Ultrasound-guided sclerotherapy with 95% ethanol is an effective therapy for ovarian endometriomas. Retention of ethanol is more effective than irrigation only.

Effect of a Sonographically Diffusely Enlarged Uterus Without Distinct Uterine Masses on the Outcome of In Vitro Fertilization–Embryo Transfer

Purpose:Our objective was to study the effect of a sonographically diffusely enlarged uterus without distinct uterine masses on the outcome of in vitro fertilization–embryo transfer (IVF-ET).Methods:Nineteen primary infertility patients undergoing IVF-ET who had a sonographically diffusely enlarged uterus without distinct uterine masses were enrolled. An age-controlled group of 144 primary infertility patients undergoing IVF-ET with a normal uterus and no history of uterine surgery was included.Results:The age, day 3 follicle stimulating hormone, antral follicle count, ovarian response, endometrial thickness, number of retrieved and fertilized oocytes, number of transferred embryos, clinical pregnancy rate, and total delivery rate were not statistically different between the two groups (P > 0.05). Patients with a sonographically diffused enlarged uterus without distinct uterine masses had a higher spontaneous abortion rate (66.7%) than controls (P < 0.04; odds ratio = 7.5;95% confidence interval, 1.16–48.56).Conclusions:A high spontaneous abortion rate was found in patients with a sonographically diffusely enlarged uterus without distinct uterine masses undergoing IVF-ET. Enhanced luteal support was required.

Primary ovarian pregnancy

The objectives of this study were to determine how primary ovarian pregnancy was diagnosed and treated at Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China, between 1980 and 2005, and whether pelvic inflammatory disease (PID) or intrauterine devices (IUDs) played a role in the occurrence of the reviewed ovarian pregnancies. Medical records were reviewed and 54 cases identified. The state of the data base as well as clinical course, operative reports, treatment results, transvaginal ultrasonographic features for early diagnosis, and possible relationship between primary ovarian pregnancy and the presence of PID or the use of an IUD were examined. The mean age of the 54 women identified as having been treated for an ovarian pregnancy was 30.4 years (range, 21– 46 years). Of these, 52 (96%) were suspected of having an ectopic pregnancy preoperatively. The preoperative diagnosis of ovarian pregnancy, based on the observation of specific features on transvaginal ultrasonographic scanning, was correctly made in 14 cases (26%). The specific sonographic features for preoperative diagnosis were the following: an empty uterus, which was seen in all cases (100%); the presence of an ovarian cystic mass with internal echo, seen in 8 cases (15%); a characteristic double

Long-term follow-up of patients surgically treated for ruptured ovarian endometriotic cysts

OBJECTIVE Approximately 4% of women are admitted to hospitals because of ovarian cyst rupture, hemorrhage, or torsion. Endometriotic cyst rupture is a rare surgical emergency associated with severe peritonitis and pelvic adhesion, and we aimed to determine its prognosis and long-term outcome. MATERIALS AND METHODS We reviewed and analyzed the medical records of 11 patients (mean age, 31.8 ± 7.2 years) with ruptured endometrioma and a history of dysmenorrhea (4.9 ± 2.3 of maximum 10) who were surgically treated, and then regularly followed-up for more than 3 years (range, 35-261 months). RESULTS Previous ultrasound examinations revealed pelvic cysts in seven patients. Three patients had a history of endometrioma surgery. In the emergency room, eight patients complained of uterine motion tenderness. Sonography revealed residual ovarian tumors (size range, 4.2-10.4 cm), with or without fluid accumulation in the cul-de-sac. Surgical enucleation by laparoscopy or laparotomy revealed high revised American Fertility Society endometriosis scores (78 ± 20.1) as well as high adhesion scores (48.7 ± 11.3). In the postoperative period, four patients had recurrent ovarian tumors that were related to elevated serum cancer antigen 125 levels and high postoperative pain scores. In contrast, three patients who became pregnant during the postoperative period had low serum cancer antigen 125 levels and pain scores. CONCLUSION Endometrioma rupture should be considered in females presenting with sudden lower abdominal pain, associated with a history of dysmenorrhea and preexisting pelvic cysts. Emergency surgical intervention may lead to a better prognosis, particularly in patients without a history of previous endometrioma surgery.

Prediction of Pregnancy Rate of In Vitro Fertilization and Embryo Transfer in Women Aged 40 and over with Basal Uterine Artery Pulsatility Index

AbstractPurpose: The purpose was to determine the effect of basaluterine perfusion on the pregnancy rates of in vitro fertilizationand embryo transfer (IVF-ET) in women aged 40 and above. Methods: A total of 47 patient aged 40 and over underwentIVF-ET. The conception cycles and the nonconception cycleswere 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), numberof ampoules of gonadotropin used, E2 levels and endometrial thickness on the day of human chorionic gonadotropin(hCG) administration, number of retrieved and fertilizedoocytes, and number of transferred embryos were not statisticallysignificant between the conception and nonconceptioncycles. 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 inpredicting the pregnancy rate of IVF in patients aged ≥ 40were demonstrated. The best prediction rate was achievedby a pulsatility index cutoff of < 2.0 for a receptive uterus. Conclusions: Increased uterine perfusion in the early follicularphase enhanced the pregnancy rate of IVF in womenaged 40 and above. It is therefore essential that patientsaged ≥ 40 with poor basal uterine perfusion should beidentified early in the early follicular phase of the menstrualcycle to apply appropriate intervention to improve the uterinecirculation for the subsequent chance of pregnancy.

Ovarian pregnancy following intrauterine insemination.

Primary ovarian pregnancy, which was first reported by Saint Maurice in 1692 [1], represents 1e3% of all ectopic pregnancies [2,3]. Its incidence after natural conception ranges from 1 in 7000 to 1 in 60,000 [2,4,5], and it remains a rare phenomenon despite the increased incidence of ectopic pregnancies following assisted conception [6]. Ovarian pregnancy occurs in the corpus luteum and often results in ovarian rupture and massive hemoperitoneum. Clinical diagnosis is tricky, and intraoperative detection requires a high index of suspicion. Several theories have been suggested to explain the ovarian implantation of the conceptus following natural conception [3,7] and in vitro fertilization [6e8]. Here, we report a case of ruptured intrafollicular primary ovarian pregnancy with hemoperitoneum that followed superovulation and intrauterine insemination. A nulliparous 24-year-old woman presented to the emergency room with bilateral lower abdominal pain. She had a 2year history of primary infertility and had been diagnosed with polycystic ovarian syndrome. She underwent two controlled, ovarian stimulation cycles induced by clomiphene citrate (Clomid; Merrel-Dow, France S.A., Neuilly-sur-Seine, France). The insufficient ovarian response prompted a third cycle with 100 mg clomiphene citrate for 5 consecutive days beginning on days 3e7 of the cycle, and two ampoules of human menopausal gonadotropin (Pergonal; I.F. Serono S.P.A., Rome, Italy) per day on days 5e9. Baseline transvaginal ultrasound (US) scan was performed at the beginning of the first treatment cycle to exclude residual ovarian cysts. US scans were repeated between days 10 and 12 of the cycle to confirm the follicular development. The scan on the night of cycle day 12 revealed three large follicles on the left ovary (mean diameter: 17 2.1 mm) and two large follicles on the right ovary