Jiann-Loung Hwang

Cesarean scar pregnancy: issues in management

To evaluate our experience with the diagnosis and treatment of Cesarean scar pregnancy.

Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study

Background.  The purpose of this study was to compare peri‐operative morbidity, preoperative sonographic estimation of uterine weight and postoperative outcomes of women with uterine fibroids larger than 6 cm in diameter or uteri estimated to weigh at least 450 g, undergoing either vaginal, laparoscopically assisted vaginal or abdominal hysterectomies.

Increase in the expression of killer cell inhibitory receptors on peritoneal natural killer cells in women with endometriosis

OBJECTIVE Malfunction of peritoneal natural killer cells (NK) may result in endometriosis. The present study was designed to determine whether the decrease in NK cytotoxicity occurs at early and advanced stages of endometriosis and is due to the increase in the NK inhibition receptors. DESIGN A case control study. SETTING A tertiary-care infertility center . PATIENT(S) A total of 44 women (controls, n = 11; women with early-stage endometriosis, n = 11; and women with advanced-stage endometriosis, n = 22) were included in this study. INTERVENTION(S) Laparoscopic examination. MAIN OUTCOME MEASURE(S) NK cytotoxicity was determined by assay of (51)Cr release against K562 cells, and the expression of killer cell inhibitory receptors (KIR, including NKB1, GL183, and EB6) in NK cells was examined by flow cytometry. RESULT(S) Women with endometriosis showed a decrease in peritoneal NK cytotoxicities against K562 at early and advanced stages of endometriosis. The expression of KIR (NKB1 and EB6) was significantly elevated in the peritoneal NK cells of women with advanced-stage endometriosis compared with controls. KIR (NKB1) was also significantly increased in peritoneal NK cells of women with advanced-stage endometriosis, compared with those of women with early-stage endometriosis. CONCLUSION(S) The results of this study suggest that the decrease in peritoneal NK cytotoxicities against K562 is observed and that this disease may be partially due to the increased expression of KIR on these NK cells.

In Vitro Maturation and Fertilization of Immature Oocytes: A Comparative Study of Fertilization Techniques

AbstractPurpose: Our purpose was to investigate the factorsinfluencing maturation and fertilization of immature oocytes. Methods: Immature oocytes were obtained from womenundergoing cesarean section. They were cultured in thematuration medium either with or without cumulus cells. Aftermaturation to metaphase II, they were randomly fertilizedby in vitro fertilization (IVF) or intracytoplasmic sperminjection (ICSI). Results: After incubation for 48 hr, 441 oocytes (42.8%)reached metaphase II. Among them, 56.6% ofcumulus-enclosed oocytes, but only 29.2% of denuded oocytes,reached metaphase II. Of the 289 cumulus-enclosed oocytes,the fertilization rates by IVF and ICSI were 56.3 and 84.1%,respectively (P < 0.01). Of the 152 denuded oocytes, thefertilization rates by IVF and ICSI were 39.5 and 84.5%,respectively (P < 0.01). The cleavage rates, however,were similar. Conclusions: Cumulus cells are beneficial in the maturationof human oocytes in vitro and that ICSI increases thefertilization rate for the in vitro matured oocytes. Thedevelopmental potential of the fertilized oocytes, however, is similarirrespective of the fertilization method or the presence orabsence of cumulus cells.

Pregnancy after immature oocyte donation and intracytoplasmic sperm injection

OBJECTIVE To report a case of pregnancy from in vitro-matured primary oocytes fertilized by ICSI. The pregnancy occurred in a woman who was in an oocyte donation program; the womans husband had normal sperm parameters. DESIGN Case report. SETTING Private general hospital affiliated with a university hospital. PATIENT(S) A recipient with premature ovarian failure, a recipients husband with normal sperm, and a pregnant woman who donated her oocytes. INTERVENTION(S) Aspiration of immature oocytes during cesarean section, in vitro culture for maturation, ICSI of matured oocytes, coculture of fertilized oocytes. MAIN OUTCOME MEASURE(S) Fertilization of oocytes by ICSI, and cleavage of embryos by Vero cell coculture. RESULT(S) Two of seven immature oocytes became metaphase II oocytes, and both were fertilized by ICSI. The two zygotes were cocultured on Vero cells to become grade 1 two-cell embryos. Pregnancy was obtained after transfer. CONCLUSION(S) More studies are necessary to clarify whether ICSI can increase the fertilization rate of in vitro-matured primary oocytes, and to clarify the role of coculture in fertilization.

Comparison of outcome of clomiphene citrate/human menopausal gonadotropin/cetrorelix protocol and buserelin long protocol – a randomized study

This study evaluates the efficacy of a stimulation protocol with clomiphene citrate (CC)/human menopausal gonadotropin (hMG)/cetrorelix and its effects on oocyte quality and endometrium. One hundred and twenty couples with male-factor infertility who were about to undergo their first intracytoplasmic sperm injection cycles were randomized into two groups. Sixty women were stimulated with the CC/hMG/cetrorelix protocol (cetrorelix group) and 60 received the buserelin long protocol (buserelin group). Fewer oocytes were recovered in the cetrorelix group than in the buserelin group (mean ± standard deviation (SD): 11.1 ± 4.0 vs. 17.3 ± 5.8, p < 0.001); however, the percentages of metaphase II, metaphase I and germinal vesicle oocytes were similar between the two groups. Serum estradiol level was significantly lower in the cetrorelix than in the buserelin group (mean ± SD: 2600.58 ± 1189.11 vs. 3293.46 ± 1221.49 pg/ml, p = 0.006), but the endometrial thickness was similar. The implantation rates (19.2% vs. 17.7%) and the pregnancy rates (41.7% vs. 40.0%) were similar between groups. The ampoules (mean ± SD: 18.9 ± 3.0 vs. 38.9 ± 12.2, p < 0.001) and injections (mean ± SD: 6.8 ± 1.1 vs. 15.7 ± 3.1, p < 0.001) of gonadotropin used were significantly lower in the cetrorelix group than in the buserelin group. No patients in either group developed a premature luteinizing hormone surge. The present study found no statistically significant difference between the two treatment modalities with regard to pregnancy rates.

Effects of growth factors and granulosa cell co-culture on in-vitro maturation of oocytes

The maturation medium for in-vitro oocyte maturation is usually supplemented with serum. However, supplementation with serum from pregnant women adversely affects the outcome of in-vitro maturation. The purpose of the study was to assess if growth factors or granulosa cell co-culture could overcome the adverse effects of pregnant womens serum. The basal maturation medium consisted of TCM199, 75 mIU/ml human menopausal gonadotrophin (HMG), 0.2 mmol/l pyruvate, and 10% serum. The maturation medium for control 1 contained fertile Womens serum. The maturation medium for control 2 contained pregnant Womens serum. The maturation media for the study groups consisted of medium for control 2, with the addition of EGF, IGF-I, activin, TGFbeta or granulosa cell co-culture. Immature oocytes were obtained from FVB mice, and the experiment was repeated six times. After maturation, the oocytes were fertilized and cultured to blastocysts, and the cumulus cells were analysed for apoptosis. The maturation, fertilization and blastocyst rates of the control 2 group were significantly lower than those of control 1 group (P < 0.05). Addition of EGF, IGF-1, activin, TGFbeta or granulosa cell co-culture could not improve the outcome of in-vitro maturation. Cumulus cell proliferation was inhibited by pregnant womans serum. Apoptosis of cumulus cell was not related to in-vitro oocyte maturation and subsequent embryo development.

A Rapidly Growing Paraurethral Myoma with Profuse Bleeding from a Mucosal Vessel: Report of a Case

Paraurethral leiomyoma is rare. This is the first reported case of a woman with a 6 × 7 × 5 cm urethral leiomyoma with profuse vaginal bleeding. The site of bleeding was identified as the anterior vaginal mucosal vein, which we subsequently electrocauterized. Enucleation of the mass was performed smoothly with a Foley catheter to avoid damage to the urethra. Profuse bleeding from a paraurethral myoma is possibly due to increased vascularity and the prolapsed nature of the tumor in this area.

Conservative treatment of ectopic pregnancy in a caesarean section scar

A 40 year old woman was admitted with severe vaginal bleeding at seven weeks amenorrhea. In her past she had previously undergone one caesarean delivery and one miscarriage. A pregnancy test was positive and pelvic examination revealed profuse haemorrhage from the cervical canal. An ultrasound scan showed a sac embedded in the myometrium of the isthmus of the uterus (Fig. 1). The woman’s blood pressure was 94/48 mmHg, pulse was 120 bpm and haemoglobin concentration was 6.1 g/dL. A blood transfusion was given. In the operating theatre, using vaginal ultrasound guidance and an oocyte retrieval needle, vasopressin 20 units diluted in 60 mL normal saline was administered into the sac. The myometrium of the isthmus bulged with the solution of vasopressin and the bleeding became sero-sanguinous. This procedure was followed by balloon tamponade using a size 18 F Foley catheter with a three-way tap. About 30 mL of saline was injected into the balloon. The bleeding diminished after the vasopressin injection, ceasing altogether following the balloon placement. She was then given four doses of methotraxate 1 mg/kg on alternate days. The balloon was removed after 72 hours, and only spotting of blood occurred. She was discharged five days later. Her h-hCG level decreased from 7052 mIU/mL on the day of admission to 4.9 mIU/mL one month later, at which time no blood flow was detected at the isthmus of the uterus on Doppler examination. Menstruation resumed one month after her discharge from hospital.

Pyomyoma after a cesarean section

Pyomyoma, or suppurative leiomyoma, is a rare but serious complication of leiomyomas. Since 1945, only 14 cases have been reported, and the mortality was 21% (1). The high mortality probably reflects delayed diagnosis. Most cases occurred related to pregnancy or menopause, and were caused by ascending infection from the lower genital tract. Here we report a woman who developed Escherichia coli bacteremia and wound infection and Candida parapsilosis pyomyoma. This is the first case that pyomyoma was caused by Candida. Magnetic resonance imaging (MRI) of pyomyoma, which has never been reported, is also presented here.