Fu-Tsai Kung

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.

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.

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.

Progesterone elevation on the day of human chorionic gonadotropin administration is not the only factor determining outcomes of in vitro fertilization

OBJECTIVEnTo assess whether progesterone elevation is the only factor in determining outcomes of in vitro fertilization (IVF).nnnDESIGNnRetrospective cohort study.nnnSETTINGnInfertility clinic at Kaohsiung Chang Gung Memorial Hospital, Taiwan.nnnPATIENT(S)nOne thousand five hundred eight women undergoing a total of 1,508 IVF cycles.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nClinical pregnancy and live-birth rates.nnnRESULT(S)nPatients were classified into four subgroups according to their progesterone concentration on the day of human chorionic gonadotropin (hCG) triggering. The clinical pregnancy and live-birth rates were statistically significantly associated with the age of the woman, the day of embryo transfer, the progesterone concentration on the day of hCG administration, the number of transferred embryos, and the number of top-quality embryos transferred. However, after omitting the women with the highest progesterone concentration (≥1.94 ng/mL), only four factors-patient age, day of embryo transfer, number of transferred embryos, and number of top-quality embryos transferred-were statistically significantly associated with the clinical pregnancy and live-birth rates.nnnCONCLUSION(S)nProgesterone concentration on the day of hCG administration is not the only factor determining the clinical pregnancy and live-birth rates. Fresh embryos from women should be frozen with extremely high progesterone concentrations. Each patients general condition and the capacity for frozen-thawed embryo transfer should be considered before implantation.

Evaluation of the relationship between urodynamic examination and urinary tract infection based on urinalysis results

OBJECTIVEnTo determine risk factors for urinary tract infection (UTI) after urodynamic examination by evaluating patients clinical characteristics and urodynamic parameters.nnnMATERIALS AND METHODSnTwo hundred and sixty-one female patients (mean age 58.7 ± 12.3 years) from May to December 2011 who had lower urinary tract symptoms or needed definite diagnosis before pelvic floor reconstruction or anti-incontinence surgery received urodynamic examination. All patients received urinalysis on the scheduled day of urodynamic examination and 3 days after urodynamic examination. Mid-stream urine samples were obtained for urinalysis before urodynamic examination. If patients had UTI based on our urinalysis criteria before urodynamic examination, the investigation was postponed until the patient had a 3-7-day course of antibiotic treatment and urinalysis showed no UTI.nnnRESULTSnAmong 261 patients, 19 and 51 patients had UTI before and after urodynamic examination, respectively. Our data suggest that urodynamic examination causes significantly increased incidence of UTI. Increased number of vaginal births, UTI before investigation, diabetes and decreased average flow rate are risk factors for UTI after urodynamic examination.nnnCONCLUSIONnWhen the prevalence of UTI after urodynamic examination is higher than 10%, we recommend that prophylactic antibiotics should be given for high-risk patients with parameters such as older age, diabetes and multipara (>3). Those who have UTI before urodynamic examination and who are found to have a low average flow rate of less than 7 mL/second should take prophylactic antibiotics after examination.

Low-lying-implantation ectopic pregnancy: A cluster of cesarean scar, cervico-isthmus, and cervical ectopic pregnancies in the first trimester

OBJECTIVEnTo describe the treatment outcomes of aberrant ectopic implantations in the lower segment of the uterus in a cohort population and to evaluate whether or not low-lying-implantation ectopic pregnancy (LLIEP), a new term, is appropriate to include in the traditional diagnoses of cervical pregnancy (CP), cesarean scar pregnancy (CSP), and other unusual aberrant implantations in the lower segment of the uterus in the first trimester, in terms of clinical characteristics, treatment, and prognosis.nnnMATERIALS AND METHODSnForty-two women with ectopic pregnancies of <12 weeks gestational age from July 2003 to December 2008 were prospectively studied. Each patient underwent an ultrasound evaluation by an experienced consultation team and was grouped into the CP, CSP, or cervico-isthmic pregnancy (CIP) group. Patients underwent either suction dilatation and curettage (D and C) alone, or laparoscopic uterine artery blockage followed by suction D and C, to remove the aberrant trophoblasts without other adjuvant treatments. Clinical characteristics and biochemical factors, including obstetric history, patient age, body mass index (BMI), gestational age, serum hematocrit and β-hCG level, operation method, operation time, and intraoperative blood loss were evaluated.nnnRESULTSnThere were no significant differences in patient age (mean = 34.1 ± 6.4 years), previous number of cesarean deliveries (mean = 1.5 ± 0.8), gestational age (mean = 6.9 ± 1.2 weeks), serum β-hCG (mean = 35,384.3 ± 41,726.9 mIU/mL), operation time (mean = 60.3 ± 46.6 minutes), and surgical blood loss (mean = 124.7 ± 191.5 mL) among the three patient groups. The uterus was successfully preserved in all patients after treatment.nnnCONCLUSIONnThe prognosis of surgical management for ectopic implantations in the lower segment of the uterus is good. The new term LLIEP seems appropriate to cover all forms of aberrant ectopic implantations in the lower segment of the uterus in the first trimester, in terms of treatment efficacy. The use of LLIEP for preoperative ultrasound diagnosis would enable the clinician to diagnose unusual cases more easily, without the need to change the current treatment policy.

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.

Use of Flexible Hysteroscopy in Prepubertal Aged Girls with Genital Complaints

Summary Objective We describe our experience with flexible hysteroscopy and concomitant manual examination to explore the immature lower genital tract of seven prepubertal girls with genital complaints. Methods Seven early prepubertal girls aged from 1 year 3 months to 5 years 9 months presented with abnormal vaginal discharge or bleeding or occluded vaginal outlet. All these girls with different indications for vaginal inspection underwent flexible hysteroscopy under anesthesia due to the potential for lack of cooperation and psychologic impact. Results Intravaginal foreign bodies were found in two patients, together with their location and tissue reaction. The origins of vaginal bleeding were identified in two patients. Verification of vagina and cervix in three patients with ambiguous external genitalia showed no vertical fusion defects or congenital Mullerian duct abnormalities. Conclusion The advantages of safety, convenience, and effectiveness suggest that flexible hysteroscopy under anesthesia is a good substitute for traditional vaginoscopy and may help in the diagnosis of genital complaints in selected prepubertal patients in the pediatric gynecology clinic.

Comparison of the clinical outcomes of transobturator and single-incision slings for stress urinary incontinence

The aim of this study was to compare the clinical outcomes of anti‐incontinence surgeries employing the transobturator sling and single‐incision sling (SIS). Our hypothesis is that the outcome of the SIS is not inferior to the obturator sling. This retrospective study reviewed the medical records of patients who underwent anti‐incontinence surgery with the transobturator sling or SIS from July 2005 to November 2014. Patients who underwent concomitant pelvic organ reconstruction with an artificial mesh were excluded. Assessments included preoperative and postoperative urodynamic examinations, perioperative complications, and postoperative urogenital symptoms. A total of 122 women were recruited according to the inclusion and exclusion criteria. Among them, 68 patients underwent transobturator sling procedures while 54 patients underwent SIS procedures. The subjective failure rate of the transobturator sling and SIS were 10.2% and 18.5%, respectively (pu2009=u20090.292). The objective failure rate, defined as a pad test showing more than 2u2009g of urine, was 10.2% for the transobturator sling and 12.9% for the SIS (pu2009=u20090.777). SIS resulted in less blood loss, operative time, length of hospital stay, and transient voiding dysfunction after the operation. No major complication occurred after either surgical intervention. In conclusion, SIS and transobturator slings might have similar efficacy, safety, and effects on new‐onset urogenital symptoms.

Emergency Peripartum Hysterectomy due to Placenta Previa/Accreta: 10 Years' Experience

Summary Objective To identify risk factors for and sonographic findings, complications and outcomes of emergency peripartum hysterectomy due to placenta previa/accreta. Materials and Methods This was a retrospective review and descriptive study of women who underwent emergency peripartum hysterectomy due to placenta previa/accreta at Chang Gung Memorial Hospital between 1992 and 2001. All emergency peripartum hysterectomies were considered by the responsible physician to be a lifesaving procedure. Each chart was reviewed with emphasis on risk factors, sonographic findings, complications and outcomes. Results There were 16 cases of emergency peripartum hysterectomy due to placenta previa/accreta (0.6/1,000 births). The mean hospitalization time was 8 days (range, 5–24 days) and the mean operation time was about 150 minutes (range, 85–335 mins). The estimated mean blood loss was 3,800 mL (range, 2,700–12,000 mL) and the mean amount of whole blood transfused was 15 units (range, 10–38 units). Two cases of bladder injury occurred when dissecting the bladder from the lower uterine segment and cervix. Conclusion The association of placenta previa and prior cesarean delivery with placenta accreta and emergency peripartum hysterectomy is well documented. Emergency peripartum hysterectomy remains a potentially lifesaving procedure with which every practitioner of obstetrics must be familiar. In facilities that have interventional radiological services and well-trained angiographers available on a 24-hour basis, prophylactic placement of catheters for possible selective embolization may be considered in patients with placenta previa and a prior cesarean section and sonographic findings of placenta accreta. There should be a clear, tried and tested protocol for dealing with massive obstetric hemorrhage to decrease maternal morbidity and mortality.