Haim Krissi

Torsion of a fallopian tube following Pomeroy tubal ligation: a rare case report and review of the literature

A case of unilateral fallopian tube torsion following Pomeroy tubal ligation, as well as a review of the literature, is presented. Although uncommon, this entity should be considered in the differential diagnosis of abdominal pain in the female patient. Early surgical intervention by means of laparoscopy is mandatory in order to correctly diagnose and treat this complication.

Platelet-derived growth factors (PDGF-A and -B) and their receptors in human fetal and adult ovaries

There is no information regarding the presence of platelet-derived growth factors (PDGFs) and their receptors in human ovaries. The expression of PDGF-A, -B and their two receptors, PDGFR-alpha and -beta, was investigated in ovarian samples from women/girls and from human fetuses, at the protein and mRNA levels. The samples were prepared for immunohistochemical staining for PDGF-A and -B and their two receptors and in situ hybridization for the detection of the mRNA transcripts of the receptors. Total RNA was extracted from frozen ovarian samples, and the expression of PDGF-A and -B was investigated by reverse transcription-polymerase chain reaction. The proteins for PDGF-A and -B were detected in oocytes, and in granulosa cells (GC) of 50% of the follicles from women/girls. The proteins and mRNA transcripts for the two receptors were detected in oocytes (mRNA for PDGFR-beta only in 25% of the oocytes). PDGFR-alpha mRNA was expressed in GC of a minority of the samples from women/girls, whereas PDGFR-beta protein and mRNA were identified in over 50% of the GC from this source. PDGF-A and -B transcripts were identified in all the extracts. The presence of the receptors in GC suggests that PDGFs might be involved in the activation of primordial follicles.

Transplantation of frozen–thawed late-gestational-age human fetal ovaries into immunodeficient mice

OBJECTIVE To compare the development of human fetal follicles from late-gestational-age fetuses frozen-thawed gradually and slowly with dimethylsulfoxide (DMSO) or 1,2 propanediol (PROH) and sucrose after renal grafting into follicle stimulating hormone-treated immunodeficient mice. DESIGN Controlled histologic study of grafted human fetal ovaries. SETTING Major tertiary care academic center. PATIENT(S) Eleven women undergoing pregnancy termination at 22 to 33 gestational weeks. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Microscopic morphometric analysis and immunohistochemistry for proliferating cell nuclear antigen (PCNA). RESULT(S) Only follicles from samples frozen-thawed with PROH developed to secondary and antral stages 4 to 6 months after grafting, with PCNA expression in their granulosa cells. However, the number of surviving/developing follicles per section was very low (4-25 per graft), compared with 71 to 406 follicles in pretransplantation samples. Graft recovery was very high, with similar rates for transplants frozen-thawed with PROH and DMSO. Normal ovarian structure after grafting was identified only in the PROH frozen-thawed grafts. In deteriorated grafts, frozen-thawed with either DMSO or PROH, net-like hollows replaced follicles, whereas tubule-like structures were only identified in DMSO frozen-thawed grafts. CONCLUSION(S) This is the first report of the development of late-pregnancy-stage human fetal follicles in immunodeficient mice. PROH freezing-thawing supported development and survival better than DMSO. However, the low follicular survival points to the urgent need for efficient methods to enhance vascularization rate and prevent ischemia.

Outcome, complications and future fertility in women treated with uterine artery embolization and methotrexate for non-tubal ectopic pregnancy

OBJECTIVE To determine the effectiveness and safety of uterine artery methotrexate (MTX) infusion and embolization combined with systemic MTX for treatment of non-tubal ectopic pregnancy. STUDY DESIGN We retrospectively reviewed the electronic files of all women admitted to a single tertiary, university-affiliated medical center with a diagnosis of non-tubal (cervical, interstitial or cesarean section scar) ectopic pregnancy, who were treated by a combination of uterine artery MTX infusion and embolization and systemic MTX between January 2001 and March 2014. The treatment protocol included a total of 4 MTX injections in doses of 1 mg/kg/day every other day (days 1, 3, 5, 7 of the protocol) alternating with folinic acid 0.1 mg/kg (days 2, 4, 6, 8). The first or second MTX dose was administered by transcatheter intra-arterial injection during the embolization procedure just before injecting Gelfoam for bilateral uterine artery occlusion, and the remaining doses were given intramuscularly. RESULTS During the study period, 25 women underwent uterine artery infusion and embolization combined with systemic MTX treatment for non-tubal ectopic pregnancy. Ten of the pregnancies were cervical, 9 were interstitial, and 6 were cesarean scar pregnancies. Mean gestational age and beta-human chorionic gonadotropin (β-HCG) level at admission were 68.6±12.9 days and 14,179 (range 436-61596) IU/L, respectively. Treatment was successful in 24 patients (96%) with mean β-HCG resolution time of 52.6 (6-147) days. Mild immediate side effects were reported including 8 cases (32%) of abdominal discomfort, 3 cases (12%) of groin or leg pain and 3 cases (12%) of puncture-site local skin infection. No serious immediate side effects such as internal vascular bleeding, sepsis or early liver or renal failure were observed. Among 12 women who stated that they tried to conceive and were more than a year from the treatment, 10 (83.3%) had subsequent pregnancy. CONCLUSION A combination of uterine artery MTX infusion and embolization with systemic MTX seems to be an effective and safe treatment for non-tubal ectopic pregnancies in women who try to conceive.

Fibrin glue improves pregnancy rates in women of advanced reproductive age and in patients in whom in vitro fertilization attempts repeatedly fail

OBJECTIVE To evaluate the possible contribution of fibrin sealant to the ET stage of IVF. DESIGN Case-control study. SETTING An assisted reproductive technology unit that performed 2,535 treatment cycles from 1996-1997. PATIENT(S) All consecutively seen patients who underwent ET from January 1996 to September 1997. INTERVENTION(S) All women who underwent ET with the aid of fibrin sealant during the study period were compared with those who underwent standard ET (controls). Thereafter, a case-control study was conducted on the first consecutively seen 174 women who underwent ET with fibrin sealant and a control group that was matched for age and number of previous unsuccessful cycles. MAIN OUTCOME MEASURE(S) Patient age, number of previous unsuccessful IVF attempts, number of embryos transferred, and pregnancy rates. RESULT(S) During the study period, ET was performed with fibrin sealant in 265 women and by the standard procedure in 1,402 women. Women in the fibrin sealant group were significantly older. The pregnancy rate was not significantly different between the groups in the whole-cohort study (20.4% versus 23.1%), but it was significantly higher in the fibrin sealant group in the case-control study (25.3% versus 14.9%). This also was true when the older women (>35 years) and the women with > or =4 previous failed IVF attempts were analyzed separately (23.2% versus 9.8% and 26.1% versus 13.4%, respectively). CONCLUSION(S) The use of fibrin sealant in ET appears to be beneficial in women of advanced reproductive age and in patients in whom IVF attempts repeatedly fail.

PREGNANCY: Triple-Test Screening in In Vitro Fertilization Pregnancies.

Purpose: To determine whether the results of triple-test analysis differ between spontaneous and IVF pregnancies.Methods: The study population consisted of 140 women with singleton pregnancies, 70 by IVF, and 70 by spontaneous conception. The groups were matched for maternal age, gestational week, and laboratory batch. The levels of all triple-test markers—alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and unconjugated estriol (u-E3)—were compared between the groups.Results: Significantly higher HCG levels were detected in the patients with IVF pregnancies than in the control group (1.31 ± 0.8 vs. 0.95 ± 0.5 multiple of the medians, respectively, (p < 0.006), but there were no significant differences in AFP or u-E3 levels. Overall, 18.5% of the IVF group were found to be screen-positive as compared with 11.4% of the control group (difference not statistically significant). Only 8 IVF pregnancies (11.4%) reached the lowest calculated risk possible (1:9999) compared with 17 (24.2%) in the control group (p < 0.05).Conclusions: Our findings support previous data demonstrating elevated maternal serum HCG in IVF patients in comparison with spontaneous ones.

Presentation, Diagnosis, and Treatment of Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE To describe the clinical characteristics and treatment of ovarian torsion in premenarchal girls with surgically verified ovarian torsion. DESIGN AND PARTICIPANTS A retrospective cohort study design was used. The medical charts of all premenarchal girls with surgically verified ovarian torsion treated in a university-affiliated tertiary medical center from 1997 to 2012 were reviewed for clinical, treatment, and outcome data. RESULTS Thirty-two premenarchal girls were identified. Their median age was 9 years. There were 7 recurrences during the study period (17.9%), for a total of 39 cases. The main presenting symptoms were abdominal pain (92.3%) and nausea and vomiting (84.6%). Physical examination revealed abdominal tenderness in 25 cases (64.1%). Abdominal ultrasound, performed in 31 patients (38 cases), yielded pathologic findings in 28 (73.7%), mainly an enlarged ovary (11 cases, 28.9%). Doppler flow studies were abnormal in 15 cases. In 26 cases (68.4%), the tentative preoperative working diagnosis was ovarian torsion. Laparoscopy was performed in 26 cases, laparotomy in 10, and laparoscopy converted to laparotomy in 3 cases. Conservative management, mainly with additional cyst drainage or cystectomy, was used in 37 cases (95.2%) with oophoropexy in 5 cases. Two patients required oophorectomy because of a suspected neoplasm and severe ovarian necrosis. Pathologic examination demonstrated 5 simple cysts, 1 necrotic ovary, and 1 mature cystic teratoma. CONCLUSIONS Ovarian torsion in premenarchal girls is associated with nonspecific signs and symptoms. Abdominal ultrasound and Doppler imaging may assist in the diagnosis. Laparoscopy with conservative management is preferred. Owing to the high recurrence rate, oophoropexy may be considered.

The association between Mullerian anomalies and short-term pregnancy outcome.

Abstract Objective: To determine the association between Mullerian anomalies (MuAs) and short-term perinatal outcome. Study design: A retrospective cohort study, comparing pregnancy outcome in women with and without MuAs matched by age, number of fetuses and parity in a 1:2 ratio. Results: Among 243 women with MuAs, 156 (64.2%) had bicornuate uterus, 38 (15.6%) had septate uterus, 27 (11.1%) had unicornuate uterus and 22 (9.1%) had didelphic uterus. Compared to controls (n = 486), women with MuAs had higher rates of previous preterm deliveries (PTDs) (20.2 versus 5.9%, p < 0.001) and previous cesarean section (CS) (50.6% versus 12.5%, p < 0.001). Women with MuAs had higher rates of PTDs <37 weeks (25.1% versus 6.1%, p < 0.001) and <32 weeks (4.1% versus 0.6%, p = 0.001), preterm premature rupture of membranes (PPROM) (12.8% versus 2.7%, p < 0.001) and small for gestational age (SGA) infants (12.3 versus 6.8%, p = 0.01). There was higher rate of CS in the MuA group (82.3 versus 22.1%, p < 0.001), mainly due to higher rates of malpresentation and previous CS. In multivariate analysis, MuA was associated with SGA (2.04, 1.15–3.63), PTDs <37 weeks (3.72, 1.79–7.73), PTDs <32 weeks (7.40, 1.54–35.56), PPROM (6.31, 3.04–13.12), malpresentation (21.62, 12.49–37.45) and retained placenta (4.13, 1.73–9.86). No increased risk was observed in the rate of in-labor CS (0.52, 0.21–1.30, p = 0.16). When the rate of adverse outcomes was stratified according to MuAs subtypes, women with unicornuate uterus had the highest rate of breech presentation at delivery (55.6%) and women with didelphy uterine had the highest proportion of PTDs <37 weeks (40.9%). Conclusion: Women with MuAs are at increased risk for adverse pregnancy outcome, mainly PTDs + and PPROM, SGA infants and CS due to malpresentation. However, the risk of in-labor CS is not increased compared to the general population.

Fistula formation after large loop excision of the transformation zone in patients with cervical intraepithelial neoplasia

This is the first report in the medical literature of two cases of rectal and bladder fistula formation after large loop excision of the transformation zone. Large loop excision of the transformation zone (LLETZ) is a well-known and effective method for the treatment of high-grade squamous intraepithelial lesions (HG-SIL). It is usually colposcopically guided and has the advantage of being simultaneously diagnostic and therapeutic. Since there is only minimal tissue damage, the specimen can be used to rule out invasive carcinoma. Complications of the LLETZ procedure are few and include mainly intraoperative and postoperative bleeding, infection and, rarely, infertility caused by cervical stenosis from damage to the cervical channel. We present two cases of rectovaginal and vesicovaginal fistula, which occurred as a consequence of LLETZ. Our review of the English literature of the last 20 years yielded no similar reports. The purpose of this article is to point out the potential hazards of loop electrosurgical excision.

Keratinocyte growth factor and its receptor in human ovaries from fetuses, girls and women

Keratinocyte growth factor (KGF) promotes growth of rat pre-antral follicles. There is limited information regarding its presence or that of its unique receptor (KGFR) in human ovaries, specifically in pre-antral follicles. The aim of the study was to investigate the expression of KGF and KGFR in ovarian samples from human fetuses and girls/women. The samples were prepared for immunohistochemical study of the KGF protein and for in situ hybridization to localize mRNA transcripts of KGFR. Total RNA was extracted from frozen ovarian samples, and the expression of KGF mRNA transcripts was investigated by reverse transcriptase polymerase chain reaction. In both fetuses and girls/women, the protein for KGF was detected from primordial stages in oocytes, granulosa cells (GCs) and stroma cells. Its mRNA transcripts were also detected in all extracts. The mRNA transcripts for KGFR were detected mainly in stroma cells in ovarian samples from both sources; in 10% of the samples, follicular staining was noted also in oocytes and GCs. Further studies adding KGF to the culture medium are needed to elucidate its putative role in human primordial follicle activation.