Jennifer K.Y. Ko

Caesarean scar pregnancy: a 10-year experience.

To review the management and outcome of all women with caesarean scar pregnancy (CSP) at a single centre.

Time to Revisit the Human Chorionic Gonadotropin Discriminatory Level in the Management of Pregnancy of Unknown Location

The purpose of this study was to review the management and outcomes of all patients with pregnancy of unknown location who had serum human chorionic gonadotropin (hCG) levels greater than 1000 mIU/mL in our institution and to determine the likelihood of a subsequent normal intrauterine pregnancy at different hCG discriminatory levels.

An in vitro study of the effect of mifepristone and ulipristal acetate on human sperm functions

Ulipristal acetate (UPA) and mifepristone are currently well‐established agents for emergency contraception. Both drugs are selective progestogen receptor modulators which have been shown to have better efficacy than the widely used levonorgestrel in prevention of pregnancy. However, there is only limited information on the action of UPA on sperm function. The present study compared the in vitro biological effects of mifepristone and UPA on human sperm functions. Spermatozoa from semen samples with normal semen parameters were isolated. Capacitated spermatozoa were pre‐incubated with 0.04, 0.4, 4 and 40 μm mifepristone or UPA for 1 h. Sperm motility, viability, DNA integrity, capacitation, spontaneous acrosome reaction, spontaneous hyperactivation, zona pellucida (ZP) binding capability and intracellular calcium concentration ([Ca2+]i) were determined. The effects of mifepristone and UPA on progesterone‐induced acrosome reaction, hyperactivation and [Ca2+]i were also studied. Our results showed that mifepristone and UPA dose‐dependently suppressed progesterone‐induced acrosome reaction, hyperactivation and [Ca2+]i at concentrations ≥0.4 μm in human spermatozoa. Both compounds did not affect sperm motility, viability, DNA integrity, capacitation, spontaneous acrosome reaction, spontaneous hyperactivation, ZP binding capability and [Ca2+]i. This study demonstrated that UPA and mifepristone modulate human sperm functions by acting as progesterone antagonists. The results enable us to gain a better understanding of the mechanisms by which mifepristone and UPA work for emergency contraception, and provide a scientific basis for their clinical application.

Two-dimensional versus three-dimensional laparoscopy: evaluation of physicians' performance and preference using a pelvic trainer

STUDY OBJECTIVE To compare the proficiency and preference of physicians in performing standard tasks in a box trainer using 2-dimensional (2D) versus 3-dimensional (3D) laparoscopy. DESIGN Prospective randomized controlled trial. DESIGN CLASSIFICATION Prospective, randomized controlled trial (Canadian Task Force classification I). SETTING Tertiary care teaching hospital. PARTICIPANTS Thirty physicians from the Department of Obstetrics and Gynecology. INTERVENTION Participants were randomly assigned to perform a set of 3 to 4 tasks in a pelvic trainer using 2D laparoscopy first and then 3D laparoscopy, and vice versa. MAIN RESULTS AND MEASUREMENTS The time taken to complete the tasks and side effects experienced were noted. Participants were asked to complete a modified Global Operative Assessment of Laparoscopic Skills (GOALS) form at the end of their tasks to evaluate their experiences and to assess their own proficiency with both visual modalities. RESULTS The time taken for peg transfer, duct cannulation, and suturing was significantly faster using 3D laparoscopy compared with 2D laparoscopy. There were no significant differences in the time taken for pattern cutting with both visual modalities. Participants experienced more dizziness using 3D laparoscopy (6.9% vs 37.9%; p = .004). The GOALS self-evaluation score was significantly higher for 3D compared with 2D laparoscopy. After the study, 11 of 29 (37.9%) participants preferred 2D, 16 of 29 (55.2%) preferred 3D, and 1 of 29 (8.3%) had no preference. CONCLUSION Although 3D laparoscopy scored higher on self-evaluation and was preferred by more participants, it only gave better objective performance in the completion of some selected tasks by participants with intermediate skill levels and was associated with more dizziness. Further studies are needed to determine the value of 3D laparoscopy, especially when used in the clinical setting.

Cesarean scar molar pregnancy

BACKGROUND: Molar pregnancy found in a cesarean scar is exceedingly rare. It can be challenging to manage and can have potentially catastrophic consequences. CASE: A 34-year-old multigravid woman presented with persistent symptoms of pregnancy after a surgical termination of pregnancy. Cesarean scar molar pregnancy was suspected on ultrasonography, and suction evacuation was performed under ultrasound guidance. This was followed by bimanual compression, oxytocin, and uterine artery embolization to reduce bleeding. CONCLUSION: A high index of suspicion is needed for early diagnosis and management of cesarean scar molar pregnancy.

Serum adiponectin is independently associated with the metabolic syndrome in Hong Kong, Chinese women with polycystic ovary syndrome

Abstract Objective: To evaluate the association of serum adiponectin level with the metabolic syndrome in Chinese women with polycystic ovary syndrome (PCOS). Methods: This was a cross-sectional study carried out in Hong Kong Chinese women with PCOS at a university-affiliated tertiary hospital between January 2010 and January 2011. Clinical and biochemical parameters of the women were analysed. Prediction of the metabolic syndrome was determined by receiver–operator characteristic (ROC) curves, univariate and multivariate logistic regression analyses. Results: A total of 116 women diagnosed to have PCOS were analysed. The area under the ROC curve of adiponectin for the prediction of metabolic syndrome was 0.820, 95% confidence interval (CI) 0.737–0.886. Univariate binary logistic regression showed that testosterone, sex hormone-binding globulin (SHBG), free androgen index (FAI), waist circumference, body mass index (BMI), quantitative insulin-sensitivity check index (QUICKI), homeostasis model assessment of insulin resistance (HOMA-IR) and adiponectin were significantly associated with the metabolic syndrome. On multivariate logistic regression analysis, adiponectin (p =  0.020), HOMA-IR, age (p =  0.011) and BMI (p =  0.019) were independently associated with the metabolic syndrome, but not FAI (p =  0.256). Conclusions: Serum adiponectin is independently associated with the metabolic syndrome in Chinese women with PCOS. Further longitudinal follow-up studies are needed to determine whether serum adiponectin adds to the prediction of long-term cardiometabolic morbidity conferred by age, BMI and measures of insulin resistance.

A questionnaire study on the acceptability of self-sampling versus screening by clinicians for Group B Streptococcus

Background Group B Streptococcus (GBS) is a leading cause of neonatal morbidity and mortality. In an effort to reduce the impact of this serious affliction, universal screening for GBS has been adopted in many countries. The objective of this study was to examine the acceptability of self‐collected GBS swabs in a local population in Hong Kong. Methods This study is a cross‐sectional questionnaire survey conducted in a tertiary teaching hospital. A total of 327 pregnant women who attended the antenatal clinic for GBS screening from April 2012 to May 2012 were included in our study. The acceptability of GBS self‐screening and its associated factors were analyzed. Results Of these women, 200/320 (62.5%) participants preferred screening by healthcare workers, whereas only 18/320 (5.6%) preferred self‐screening. The most common reasons why some participants preferred to be screened by clinicians were that professionals had greater knowledge, and the added worry about the accuracy of self‐screening. 22/320 (69.4%) and 195/320 (60.9%) women believed that they felt comfortable enough to self‐perform the vaginal swab and rectal swab respectively. Previous use of tampons was associated with higher perceived capability of self‐performing the vaginal swab. Perceived capability to self‐perform the rectovaginal swabs was associated with a willingness to self‐perform the swabs (p < 0.001). The majority of women, 303/320 (94.7%), found the current practice of an additional clinic visit for GBS screening acceptable. However, 218/320 (68.1%) participants would like to undertake self‐screening if they were given the chance to do so in the next pregnancy, and 187/320 (58.4%) would recommend others have self‐screening for GBS as well. Conclusion Most women in the local population still preferred physician‐collected samples for GBS screening, but they welcomed the option of self‐screening in future pregnancies. Improved health education about the importance of GBS screening may improve the willingness of women to perform self‐screening.

A 12‐year experience of the management and outcome of heterotopic pregnancy at Queen Mary Hospital, Hong Kong, China

Heterotopic pregnancy is a rare form of pregnancy that involves the simultaneous occurrence of an ectopic pregnancy and an intrauterine pregnancy. Patients often present late because of false reassurance following detection of an intrauterine pregnancy and the limited usefulness of serial serum human chorionic gonadotropin (hCG)monitoring [1,2]. Themanagement of heterotopic pregnancy is particularly challenging because the goal is not only to remove the ectopic pregnancy before it ruptures, but to be as minimally invasive as possible to preserve the intrauterine pregnancy [2,3]. The aim of the present study was to review all patients who had heterotopic pregnancy over a 12-year period at the Department of Obstetrics and Gynecology, Queen Mary Hospital, University of Hong Kong, China. A retrospective chart review was performed for patients diagnosed with heterotopic pregnancy between January 2000 and December 2011. Data regarding the presenting symptoms, diagnostic features, and management outcomes were analyzed. A total of 13 patients with heterotopic pregnancy were identified (Table 1), giving an overall incidence of 0.03% based on the total number of deliveries (n=46 781) at the institution over the same study period. Coexisting with the intrauterine pregnancies, 9 patients had tubal pregnancy, 2 interstitial pregnancy, 1 ovarian pregnancy, and 1 cesarean scar pregnancy. Eleven (84.6%) patients had conceived after assisted reproductive technology (ART) procedures. Seven patients underwent ART at the hospital and, using a denominator of all clinical pregnancies following ART (n=3523), the incidence of heterotopic pregnancy after ART was 0.20%. The mean gestational age at the time of diagnosis was 7.9± 2.3 weeks. Ten (76.9%) patients presented with abdominal pain, 1 (7.7%) with vaginal bleeding, and 2 (15.4%) were asymptomatic. Six (46.1%) patients had hemoperitoneum on laparoscopy. The diagnosis wasmissed at initial ultrasonography in 8 (61.5%) patients. Treatment modalities of all patients are listed in Table 1. Ten (76.9%) patients had a viable intrauterine pregnancy at the time of diagnosis; of these, 7 (70%) patients went on to have delivery at term, 1 (10%) had a preterm twin delivery at 32 weeks, 1 (10%) patient decided to terminate the pregnancy, and 1 (10%) patient had an uneventful ongoing pregnancy at 35 weeks, as indicated in the last follow-up record at the time of the review. The patient with a cesarean scar ectopic pregnancy had a cesarean delivery complicated by primary postpartum hemorrhage due to massive bleeding from the ectopic implantation site, which was subsequently controlled by uterine artery embolization. There was an increase in the incidence of heterotopic pregnancy over the years: 3 patients in 2000–2005 compared with 10 patients in 2006–2011. This finding is consistent with previous reports that heterotopic pregnancy is associated with the application of ART [1,2]. Of note is the increased likelihood of nontubal heterotopic ectopic pregnancy, the diagnosis of which may be missed unless the physician has a high index of suspicion for this condition. Increased physician awareness, particularly in patients who have undergone ART, is important for early diagnosis and management of this condition. If the heterotopic pregnancy is managed appropriately, the obstetric outcome of the coexisting intrauterine pregnancy appears to be favorable.

Scratching and IVF: any role?

Purpose of review To review updated information on the influence of endometrial scratching on IVF. Recent findings Endometrial receptivity remains an important rate-limiting step affecting the success of IVF. The current evidence on the effect of endometrial scratching on IVF ranges from marked improvement, no difference to a potentially negative impact. The heterogeneity of studies presents a challenge in interpretation of data for routine clinical practice. Summary Endometrial scratching performed in the preceding cycle is associated with improved clinical pregnancy and live birth rates in women with recurrent implantation failure, but not in unselected subfertile women undergoing IVF. Most of the current literature are underpowered and at high risk of bias.

Sperm fucosyltransferase-5 mediates spermatozoa–oviductal epithelial cell interaction to protect human spermatozoa from oxidative damage

Oxidative damage by reactive oxygen species (ROS) is a major cause of sperm dysfunction. Excessive ROS generation reduces fertilization and enhances DNA damage of spermatozoa. Interaction between spermatozoa and oviductal epithelial cells improves the fertilizing ability of and reduces chromatin damage in spermatozoa. Our previous data showed that oviductal epithelial cell membrane proteins interact with the human spermatozoa and protect them from ROS-induced reduction in sperm motility, membrane integrity and DNA integrity. Sperm fucosyltransferase-5 (sFUT5) is a membrane carbohydrate-binding protein on human spermatozoa. In this study, we demonstrate for the first time that sFUT5 is involved in human spermatozoa-oviduct interaction and the beneficial effects of such interaction on the fertilizing ability of human spermatozoa. Anti-sFUT5 antibody-treated spermatozoa had reduced binding to oviductal membrane proteins. It is consistent with the result that affinity-purified sFUT5 is bound to the epithelial lining of human oviduct and to the immortalized human oviductal epithelial cell line, OE-E6/E7. Pretreatment of spermatozoa with anti-sFUT5 antibody and oviductal membrane proteins with sFUT5 suppressed the protective action of oviductal membrane proteins against ROS/cryopreservation-induced oxidative damage in spermatozoa. Asialofetuin, a reported sFUT5 substrate, can partly mimic the protective effect of oviductal epithelial cell membrane proteins on sperm motility, membrane and DNA integrity. The results enhance our understanding on the protective mechanism of oviduct on sperm functions.