Fu-Jen Huang

Major complications associated with laparoscopic-assisted vaginal hysterectomy: ten-year experience.

STUDY OBJECTIVEnTo describe our experience with major complications associated with laparoscopic-assisted vaginal hysterectomy (LAVH) and compare our results with those of the American Association of Gynecologic Laparoscopists (AAGL) membership survey and another similar study.nnnDESIGNnRetrospective study (Canadian Task Force classification II-3).nnnSETTINGnUniversity-affiliated hospital.nnnPATIENTSnTwo thousand seven hundred two women. Intervention. LAVH.nnnMEASUREMENTS AND MAIN RESULTSnDemographic data and medical histories (age, parity, surgical indications, pathologic findings, major complications) were analyzed. Major complications were 11 bladder injuries, 4 ureter injuries, 11 bowel injuries, 2 vascular injuries, 2 cases of massive bleeding from the vaginal cuff or colpotomy wound with associated impending shock, 2 cases of postoperative ileus, and 2 pelvic abscesses. Our overall major complication rate was 1.3% compared with 2.7% in the AAGL 1995 membership survey (p <0.001). Similar rates of febrile morbidity (2.2% and 2.0%), bleeding requiring transfusion (0.05% and 0.06%), and bowel, ureteral, or bladder injury (1.0% and 1.0%) were noted between our study and the other 1995 study (all p >0.05). Of 34 major complications in our study, 24 occurred during hysterectomy performed by inexperienced general gynecologists and 10 by an experienced endoscopist (p = 0.005).nnnCONCLUSIONnThe rate of major complications associated with LAVH can be reduced when the procedure is performed by a well-trained laparoscopic surgeon compared with a less-experienced general gynecologist.

Relationship of the Human Cumulus-Free Oocyte Maturational Profile with In Vitro Outcome Parameters After Intracytoplasmic Sperm Injection

Purpose:We investigated whether the human oocyte maturational profile at the removal of cumulus/corona cells affects the fertilization rate and subsequent embryo quality after intracytoplasmic sperm injection.Methods:A total of 1011 oocytes from 150 cycles was included in this retrospective analysis. Cumulus-free oocytes that were in prophase or metaphase I of meiosis at the removal of cumulus/corona cells were incubated in vitro until they reached metaphase II (in vitro-matured oocytes) and were then immediately injected with a single spermatozoa. Oocytes that were in metaphase II at the removal of cumulus/corona cells (MII oocytes) received sperm injection after 3–4 hr of preinjection incubation.Results:The fertilization rate of the MII oocytes was significantly higher than that of in vitro-matured oocytes (81 vs 62%; P < 0.001). The cleavage rates were similar in the two groups (MII oocytes, 94%; in vitro-matured oocytes, 91%). However, MII oocytes had significantly higher percentages of good-quality embryos (grade 1–3 embryos, 87 vs 58%, P < 0.001) and embryos with high cumulative embryo scores (score 10–32 embryos, 62 vs 33%, P < 0.001). The mean cumulative embryo score of MII oocytes after fertilization was also higher than that of in vitro-matured oocytes (12.1 ± 3.8 vs 8.8 ± 3.4; P = 0.014).Conclusions:MII oocytes that extruded the first polar body at the removal of cumulus/corona cells had better fertilization rates and embryo morphology than in vitro-matured oocytes that extruded the first polar body following the removal of cumulus/corona cells and in vitro culture.

Human oocyte maturity in vivo determines the outcome of blastocyst development in vitro

AbstractPurpose: To date, the impact of oocyte maturity at aspiration on the blastocyst formation in vitro has not been fully evaluated. This study was undertaken to assess the influence of oocyte maturity in patients undergoing in vitro fertilization and blastocyst transfer program.nMethods: A total of 1278 oocytes derived from 147-IVF cycles were retrospectivly analyzed. Oocyte maturity was graded on a scale from 1 to 5 based on the morphology of the ooplasm, cumulus mass, corona radiata, and membrana granulosa cells.nResults: Mature oocytes yielded the highest fertilization rates. Although the cleavage rates were similar in both groups, the percentage of poor morphology, day-3 embryos from the nonmature-oocyte group was significantly higher than from the mature-oocyte group (54.7% vs. 15.5%, P < 0.001). Although good morphology, day-3 embryos were collected from nonmature oocytes, the incidence of these embryos developing to the blastocyst stage was significantly less than from mature oocytes (33.3% vs. 71.2%, P < 0.001). Although blastocyst stage embryos were collected from nonmature oocytes, the incidence of these embryos developing to the top-scoring blastocysts was significantly less than from mature oocytes (58.3% vs. 89.5%, P < 0.001).nConclusions: These phenomena suggest that oocyte maturity produced in vivo determine the fertilization potential and subsequent blastocyst quality in vitro.

Laparoscopic-Assisted Vaginal Hysterectomy in Women of all Weights and the Effects of Weight on Complications

STUDY OBJECTIVEnTo compare intraoperative and postoperative complication rates for laparoscopic-assisted vaginal hysterectomy (LAVH) between women classified as obese, normal weight, or very thin based on body mass index (BMI).nnnDESIGNnRetrospective cohort study (Canadian Task Force classification II-3).nnnSETTINGnUniversity hospital.nnnPATIENTSnSix hundred seventy women (162 with BMI >25, 34 with BMI <18.5, 474 with BMI 18.5-25 kg/m(2)).nnnINTERVENTIONnLAVH.nnnMEASUREMENTS AND MAIN RESULTSnFor women with high BMIs, 34 procedures (21.0%) were converted to laparotomy, compared with 48 (10.1%) for women of normal body weight and 3 (8.8%) for those with low BMI (p = 0.001). Average blood loss was 299.3 +/- 87.8, 219.1 +/- 57.5, and 231.8 +/- 65.9 ml, respectively (p <0.001). Very thin women had similar intraoperative and postoperative complication rates (8.8 %) as women of normal body weight (8.6%) and obese women (11.1%).nnnCONCLUSIONnObese women had increased likelihood of conversion to laparotomy and greater blood loss after LAVH than nonobese women. Very thin women had similar intraoperative and postoperative complication rates as women of normal body weight and obese women.

CLINICAL ASSISTED REPRODUCTION: Determination of the Efficiency of Controlled Ovarian Hyperstimulation in the Gonadotropin-Releasing Hormone Agonist-Suppression Cycle Using the Initial Follicle Count During Gonadotropin Stimulation

Purpose: Our purpose was to evaluate the relationship between the initial follicle count during gonadotropin stimulation after gonadotropin-releasing hormone (GnRH) agonist suppression and the efficiency of controlled ovarian hyperstimulation (COH) in patients receiving treatment with assisted reproductive technologies (ARTs).Methods: A total of 338 COH procedures in 291 couples was performed with cycles that reached the stage of oocyte retrieval. The ovarian antral follicle number was measured using transvaginal ultrasonography at the folliculometry during gonadotropin stimulation by GnRH agonist suppression in patients undergoing ARTs. Controlled ovarian hyperstimulation was accomplished using GnRH agonist down-regulation combined with FSH and menotropin stimulation. The characteristics of oocytes after retrieval and embryos after in vitro culture and the pregnancy rates were assessed.Results: The procedures performed included 195 ET cycles, 129 TET cycles, and 14 incomplete cycles. The treatment cycles were divided into four categories according to the antral follicle number (i.e., ≤5, 6–10, 11–15, and ≥16) at the first folliculometry to evaluate the influence of various factors. The antral follicle count correlated significantly with the patient age, dosage of gonadotropins, serum estradiol concentration, number of antral follicles (≥13 mm) while receiving hCG injections, number of oocytes retrieved, and, later, number of embryos transferred. There was a trend toward an increasing number of pregnancies per cycle as the number of antral follicles increased (14.7, 26.5, 44, and 45%, respectively).Conclusions: We were able to predict the efficiency of COH and outcome of ARTs based on the follicle count during the first folliculometry during gonadotropin stimulation after GnRH agonist suppression. The results of the folliculometry significantly predicted the ovarian response to COH and the outcome of ARTs in the current treatment cycle.

Comparison of one- and two-layer vaginal cuff closure and open vaginal cuff during laparoscopic-assisted vaginal hysterectomy

STUDY OBJECTIVEnTo evaluate clinical outcomes of three surgical techniques during laparoscopic-assisted vaginal hysterectomy.nnnDESIGNnProspective, randomized study (Canadian Task Force classification I).nnnSETTINGnMedical school-affiliated hospital.nnnPATIENTSnFour-hundred twenty-seven women.nnnINTERVENTIONnBy means of a computer-generated randomization code, patients were assigned immediately before operation to one of three groups according to type of surgical procedure: group 1, 147 women having one-layer closure of the vaginal cuff; group 2, 138 having two-layer closure of the vaginal cuff; and group 3, 142 having open vaginal cuff.nnnMEASUREMENTS AND MAIN RESULTSnPatients were observed for morbidity during hospitalization, and 1 and 6 weeks and 6 months postoperatively. No significant differences were found among the groups for length of surgery, operative blood loss, postoperative hematocrit, length of hospital stay, postoperative febrile morbidity, frequency of pelvic and urinary tract infection, dyspareunia, postcoital spotting, vaginal discharge, and morbidity of the cuff (cellulitis, abscess formation, bleeding, hematoma, dehiscence). Operating time was greatest for two-layer closure. The frequency of postoperative granulation of cuff tissue and vaginal discharge was greater for group 1 than for the other two groups.nnnCONCLUSIONnTwo-layer closure of the vaginal cuff during laparoscopic-assisted vaginal hysterectomy is associated with fewer instances of vaginal vault granulation and vaginal discharge than either one-layer closure or open vaginal cuff.

Short- and Long-Term Clinical Results of Laparoscopic-Assisted Vaginal Hysterectomy and Total Abdominal Hysterectomy

STUDY OBJECTIVEnTo compare short- and long-term clinical results of laparoscopic-assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH).nnnDESIGNnRetrospective cohort study (Canadian Task Force classification II-1).nnnSETTINGnUniversity-affiliated hospital.nnnPATIENTSnOne hundred fifty women who underwent LAVH and 146 who underwent TAH.nnnINTERVENTIONnHysterectomy.nnnMEASUREMENTS AND MAIN RESULTSnBlood loss during surgery, narcotic analgesic consumption, duration of hospital stay, and convalescence time were significantly higher for women who underwent TAH than for those who underwent LAVH (p <0.05). Operating time was significantly longer for LAVH than for TAH (152.2 +/- 32.4 vs 96.5 +/- 29.6 min, p = 0.014). Eight-year follow-up showed no statistically significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital spotting, and cuff granulation between procedures (p >0.05).nnnCONCLUSIONSnAlthough short-term clinical results revealed some statistically significant differences between LAVH and TAH, long-term follow-up recorded similar frequencies of surgical sequelae.

Increased Progesterone/Estradiol Ratio on the Day of hCG Administration Adversely Affects Success of In Vitro Fertilization–Embryo Transfer in Patients Stimulated with Gonadotropin-releasing Hormone Agonist and Recombinant Follicle-stimulating Hormone

OBJECTIVEnWe investigated the influence of premature luteinization in in vitro fertilization using a long protocol of gonadotropin-releasing hormone agonist (GnRHa) and recombinant follicle-stimulating hormone (rFSH), taking ovarian response into account in the definition of premature luteinization.nnnMATERIALS AND METHODSnA total of 339 cycles of controlled ovarian hyperstimulation with rFSH and GnRHa were performed in 311 infertile couples. Premature luteinization was defined as a progesterone (P) to estradiol (E2) ratio of > 1 on the day of human chorionic gonadotropin (hCG) administration. The P/E2 ratio is calculated as: P (ng/mL) 1,000/E2 (pg/mL). Clinical outcomes were compared for the prematurely luteinized and non-prematurely luteinized groups.nnnRESULTSnThe mean number of retrieved oocytes, recovered mature oocytes, embryos and top quality embryos were significantly higher in the non-prematurely luteinized group than in the prematurely luteinized group. Although fertilization rates and implantation rates were similar between the two groups, the clinical pregnancy rate was higher in the non-prematurely luteinized group than in the prematurely luteinized group.nnnCONCLUSIONnPremature luteinization, defined as late follicular P/E2 ratio of > 1 in long GnRHa cycles with rFSH stimulation, adversely affected ovarian responses and clinical outcomes. It seems unrelated to preovulatory luteinizing hormone (LH) elevation and LH/hCG content of gonadotropins and could be associated with poor ovarian response and the presence of dysmature follicles.

Characterization of Apoptosis Induced by Emodin and Related Regulatory Mechanisms in Human Neuroblastoma Cells

Emodin (1,3,8-trihydroxy-6-methylanthraquinone), a major constituent of rhubarb, has a wide range of therapeutic applications. Recent studies have shown that emodin can induce or prevent cell apoptosis, although the precise molecular mechanisms underlying these effects are unknown. Experiments from the current study revealed that emodin (10–20 μM) induces apoptotic processes in the human neuroblastoma cell line, IMR-32, but exerts no injury effects at treatment doses below 10 μM. Treatment with emodin at concentrations of 10–20 μM led to a direct increase in the reactive oxygen species (ROS) content in IMR-32 cells, along with significant elevation of cytoplasmic free calcium and nitric oxide (NO) levels, loss of mitochondrial membrane potential (MMP), activation of caspases-9 and -3, and cell death. Pretreatment with nitric oxide (NO) scavengers suppressed the apoptotic biochemical changes induced by 20 μM emodin, and attenuated emodin-induced p53 and p21 expression involved in apoptotic signaling. Our results collectively indicate that emodin at concentrations of 10–20 μM triggers apoptosis of IMR-32 cells via a mechanism involving both ROS and NO. Based on the collective results, we propose a model for an emodin-triggered apoptotic signaling cascade that sequentially involves ROS, Ca2+, NO, p53, caspase-9 and caspase-3.

A Prospective, Randomized Study of Closed-Suction Drainage after Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVEnTo estimate whether closed-suction drainage of the pelvis after laparoscopic-assisted vaginal hysterectomy reduces the risk of postoperative morbidity.nnnDESIGNnProspective, randomized study (Canadian Task Force classification 1).nnnSETTINGnTeaching medical center.nnnPATIENTSnThree hundred twenty-four women.nnnINTERVENTIONnLaparoscopic-assisted vaginal hysterectomy.nnnMEASUREMENTS AND MAIN RESULTSnThe 160 women in group 1 had closed-suction (Jackson-Pratt) drains inserted into the peritoneal cavity and cul-de-sac, whereas the 164 in group 2 had no drains. Postoperative time to flatulence, hemoglobin, analgesic requirements, duration of hospital stay, rehospitalization, complications, febrile morbidity, and infection were studied. No statistically significant differences were seen between groups in demographics, outcome measures, postoperative infectious morbidity, or complications. The small power value may mean that no true differences existed for most tests. A statistically significant difference in analgesic requirement was found, with more oral analgesics taken by women in group 2.nnnCONCLUSIONnProphylactic surgical drainage may not be necessary to prevent postoperative morbidity after laparoscopic-assisted vaginal hysterectomy when prophylactic and postoperative antibiotics are given. A drain still has its role in gynecologic laparoscopy in selected women, such as in those with persistent ooze from raw surfaces, bowel injury, or frank pus in the abdomen.