Joseph Hasson

Comparison of adnexal torsion between pregnant and nonpregnant women

OBJECTIVE The purpose of this study was to compare clinical manifestations, treatment, and pregnancy outcome of adnexal torsion in pregnant and nonpregnant women. STUDY DESIGN We conducted a retrospective case-control study in the Departments of Gynecology at 2 tertiary centers between 1999-2008. Forty-one pregnant and 77 nonpregnant women with surgically proved adnexal torsion were assessed. RESULTS Recurrence rate of torsion was 19.5% in pregnant women and 9.1% in control subjects; 73% of pregnant women conceived through assisted reproductive technologies. Doppler blood flow was falsely normal in 61% of pregnant women and in 45% of nonpregnant women; 83.3% of pregnant women delivered at term. Laparoscopic detorsion was the main surgical procedure. CONCLUSION Presentation of adnexal torsion is similar in pregnant and nonpregnant women. Past assisted reproductive technology is an important risk factor in pregnancy. Doppler blood flow has a high false-negative rate and should not outweigh clinical suspicion. Although pregnancy outcome is favorable, the high rate of recurrence raises the issue of surgical fixation at the first episode.

Histologic evaluation of fresh human ovarian tissue before cryopreservation.

Transplantation of cryopreserved tissue from patients with cancer may carry the risk of reactivation or redissemination of micrometastases. This prospective study was conducted to evaluate the potential involvement of micrometastases in ovarian tissue in cancer patients. Ovarian biopsies were collected from patients who underwent ovarian tissue cryopreservation, in our IVF unit before chemotherapy between 2000 and 2008. Indications for cryopreservation included breast cancer (n=13), osteosarcoma (n=13), hematologic malignancies (n=13), uterine cervix carcinoma (n=2), endometrial carcinoma (n=1), colon cancer (n=1), and brain medulloblastoma (n=1). The samples were stained with hematoxylin and eosin, and examined histologically. Immunoperoxidase broad-spectrum cytokeratin staining was also performed on specimens from breast cancer patients. There were 44 patients (age range 5–40 yr) who yielded 40 specimens. No gross pathologic involvement was observed, and the histologic examination revealed normal histology with no evidence of metastases. Our findings showed that for the purpose of considering ovarian tissue cryopreservation in cancer patients, the likelihood of microscopic metastases within ovaries of normal appearance is apparently very low. Clarification of the actual risk of ovarian involvement and any subsequent risk of micrometastases and tumor reimplantation requires further investigation.

Adnexal torsion: cystectomy and ovarian fixation are equally important in preventing recurrence

OBJECTIVE To report our clinical experience in adnexal torsion. STUDY DESIGN A retrospective case review of surgically proven adnexal torsion. RESULTS 216 cases were identified. Mean age was 29±12. Twenty-two were premenarchal, 59 had ovarian stimulation, 48 were pregnant (with a median gestational age of 7 weeks) and 14 were post-menopausal. The most common risk factor was a previous history of adnexal torsion. The main clinical features were sudden, intermittent pain. Forty-five percent of Doppler examinations demonstrated normal flow: premenarchal and postmenopausal patients had higher rates of abnormal flow, compared to pregnant patients or after ovarian stimulation. Median time from admission to diagnosis was 6 h. Laparoscopy was conducted in 81.0% of the cases, and laparotomy in the rest. Twenty-three cases of recurrent torsion were documented. The majority of these events occurred following detorsion only. An enlarged ovary was found in 77 cases, dermoid cyst in 8 cases, and one case was malignant. Sixty eight-cases underwent detorsion, in 82 cases a combined detorsion and cystectomy or fenestration were performed and 43 patients underwent partial or total adnexectomy. Adnexal fixation was conducted in 21 cases. Cyst drainage or cystectomy significantly reduced the chance of retorsion by 50% and 75%, respectively, compared to detorsion only. CONCLUSION Ovarian stimulation and early pregnancy are predisposing factors for ovarian torsion. Doppler flow studies may be a helpful diagnostic tool among premenarchal and post-menopausal women. Cystectomy should be considered in order to reduce the risk of retorsion.

Risk Factors, Symptoms, and Treatment of Ovarian Torsion in Children: The Twelve-Year Experience of One Center

OBJECTIVE To assess risk factors, clinical findings and mode of diagnosis and treatment in premenarchal children with surgically verified ovarian torsion (OT). STUDY DESIGN A retrospective case review (Canadian Task Force Classification II-2). SETTING Teaching and research hospital, a tertiary center. PATIENTS Premenarchal children with surgically verified OT. INTERVENTIONS Patients underwent either laparoscopy or laparotomy. RESULTS Twenty-two cases of OT in 20 premenarchal girls (median age 12 years) were identified. Three cases involved recurrent torsion after detorsion without cystectomy. The main presenting symptoms were sudden pain and vomiting. Six patients underwent Doppler examinations, and all demonstrated an abnormal flow. Seventeen interventions were by laparoscopy. Conservative management, mainly detorsion with additional cyst drainage or cystectomy, was performed in 19 cases (86.4%). Oophoropexy was performed in 3 cases (13.6%). Pathologic examination demonstrated 5 simple cysts and 1 dermoid cyst. CONCLUSIONS Ovarian torsion in premenarchal girls usually presents with intermittent abdominal pain and abdominal tenderness. Other signs and symptoms are nonspecific. When performed, Doppler imaging may assist in diagnosing ovarian torsion in children. Detorsion followed by cystectomy may prevent recurrence.

Reduction of twin pregnancy to singleton: does it improve pregnancy outcome?

Objective. To compare pregnancy complications, obstetrical and neonatal outcome of twin pregnancies reduced to singleton, with both non-reduced twin pregnancies and singleton pregnancies. Methods. A retrospective case–control study was performed at the Obstetrics and Gynecology Ultrasound unit of a tertiary referral medical center. Patients population included 32 bi-chorionic bi-amniotic twin pregnancies reduced to singleton and 35 non-reduced twin pregnancies. Thirty-six patients with singleton pregnancies comprised the second control group. Main outcome measures were rates of pregnancy complications, preterm delivery (both before 37 weeks of gestation and before 34 weeks of gestation), late abortions, intra-uterine growth retardation, cesarean section, mean birth weights, and mean gestational age at delivery. Results. The reduced twin pregnancies group had similar rates of total pregnancy complications, preterm deliveries, and cesarean section as non-reduced twins. Gestational age at delivery and mean birth weight were also similar to non-reduced twins and significantly different compared with singletons. Preterm delivery and late abortion incidences were significantly higher when reduction was beyond 15 weeks gestation. Conclusions. Reduction of twin pregnancy to singleton does not change significantly pregnancy course and outcome. Favorable obstetrical and neonatal outcomes could be achieved by performing early, first trimester reductions.

Retrieval of immature oocytes after chemotherapy for Hodgkin's disease and prolonged ovarian down-regulation with gonadotropin-releasing hormone agonist.

OBJECTIVE To describe isolation and in vitro maturation of primary oocytes from the ovarian cortex in the presence of hypothalamic pituitary down-regulation. DESIGN Case report. SETTING Tertiary care university-affiliated hospital. PATIENT(S) An 18-year-old patient was given treatment with the ABVD (Adriamycin, bleomycin, vinblastine, and dacarbazine) protocol for Hodgkins disease. She underwent ovarian tissue cryopreservation while being cotreated with GnRH agonist because of disease relapse. INTERVENTION(S) Laparoscopic oophorectomy, ovarian tissue cryopreservation, and in vitro maturation of primary oocytes. MAIN OUTCOME MEASURE(S) Maturation of primary oocytes isolated from the medium used for preparation of ovarian tissue. RESULT(S) Twenty-one immature germinal vesicle-stage oocytes were isolated from the medium of dissection. All were incubated in in vitro maturation medium, and five were maturated and frozen. CONCLUSION(S) The fact that germinal vesicle-stage oocytes were present in our patients medium despite hormonal down-regulation demonstrates that GnRH agonist does not completely inhibit antral follicle development.

Total fertilization failure in intra-cytoplasmic sperm injection cycles--classification and management.

Abstract In this retrospective cohort study we intended to propose a classification and preliminary management strategy for couples exhibiting total fertilization failure (TFF) in intra-cytoplasmic sperm injection (ICSI) cycles. Sixteen couples with a total of 27 cycles exhibiting TFF, age <40 and/or more than four M2 oocytes aspirated were enrolled. While TFF occurred in 4.3% of all 3723 ICSI cycles, in women younger than 40 with at least 5 M2 oocytes the TFF rate was 0.7%. Indications for ICSI were severe male factor and unexplained infertility. Of the 16 couples with TFF, 4 demonstrated a single episode of TFF, with either subsequent or former normal fertilizations, thus implying possible sporadic faulty laboratory conditions. Ten couples demonstrated repeated total or very low fertilization rates, hinting at a gamete defect not overcome by ICSI. Two couples experienced TFF in the first and only cycle performed at our unit. We conclude that initial and repeated TFF hints at severe gamete defects for which only donor gametes may prove successful while sporadic TFF events could simply imply a technical modifiable condition. Chinese abstract 在这项回顾性队列研究中，我们试图提出单精子卵细胞浆内注射周期完全受精失败夫妇的分类及初步管理策略。在本研究中，入组的16对夫妇一共发生了27个周期的完全受精失败，入组夫妇年龄均小于40岁，均取得了超过4个M2期卵母细胞。所有3723例单精子卵细胞胞浆内注射周期完全受精失败的发生率是4.3%，但在年龄小于40岁的妇女且至少取得5个M2期卵母细胞组的完全受精失败的发生率仅为0.7%。单精子胞浆内注射的指征是严重的男性不育因素及不明原因不孕。在发生完全受精失败的16对夫妇中，4对夫妇的完全受精失败是单次事件，她们随后的或者之前的周期中均有正常的受精，这提示是实验室条件改变的偶发失败；10对反复发作或者非常低受精率的夫妇提示了单精子胞浆内注射方法无法解决配子缺陷的问题；另外2对完全受精失败的夫妇在我们实验室有且只做了这一个周期。我们得出这样的结论：初始和重复的完全受精失败暗示严重的配子缺陷，捐赠配子可能是唯一的治疗策略。零星的完全受精失败事件可能只是意味着实验室条件的改变。

The effect of endometrial injury on implantation and clinical pregnancy rates

Abstract Aim: To assess the effect of endometrial scratching (ES) on in vitro fertilization-embryo transfer outcome (IVF-ET) Materials and methods: Retrospective matched case control study including all fresh IVF cycles performed between January 2006 and December 2012 at an academic IVF center. ES with an endometrial biopsy catheter was performed in the cycle preceding the index IVF cycle. Patients (n = 238) were pair matched with controls according to age, number of previous failed IVF cycles and number of embryos transferred. Results: Demographic and cycle characteristics were comparable in all of the following: age, number of previous cycles, number of collected oocyte, number of embryos transferred and quality of transferred embryos. Implantation, clinical and ongoing pregnancy rates were comparable in both groups (28%, 34% and 18.4% vs 30%, 40.3% and 29%, in ES group and controls, respectively). Logistic regression analysis found no significant association between ES and pregnancy rate. Conclusions: Mechanical endometrial stimulation did not improve implantation and pregnancy rates. Furthermore, no factors that may predict which patients could benefit from ES were identified. Further prospective studies are warranted to evaluate possible benefits in different subsets of patients such as patients with recurrent implantation failures.

Short communication: Post‐hysterectomy pelvic fluid collection: is it associated with febrile morbidity?

We evaluated the clinical significance and possible association of febrile morbidity with sonographically detected post‐hysterectomy fluid collections. Transvaginal ultrasound examinations were performed to assess the presence of fluid collections and correlated to clinical data. Fluid collection was detected in 27 (64%) women at postoperative day 2, in 15 (35%) at postoperative day 7 and in 5 (12%) at the fourth to fifth postoperative week. Febrile morbidity was not related to the presence, location or size of fluid collection. Postoperative pelvic fluid collections are common sonographic findings after hysterectomy and are not associated with postoperative febrile morbidity.

Timing embryo biopsy for PGD – before or after cryopreservation?

Abstract Objective: Pre-implantation genetic diagnosis (PGD) is required in order to screen and diagnose embryos of patients at risk of having a genetically affected offspring. A biopsy to diagnose the genetic profile of the embryo may be performed either before or after cryopreservation. The aim of this study was to determine which biopsy timing yields higher embryo survival rates. Study design: Retrospective cohort study of all PGD patients in a public IVF unit between 2010 and 2013. Inclusion criteria were patients with good-quality embryos available for cryopreservation by the slow freezing method. Embryos were divided into two groups: biopsy before and biopsy after cryopreservation. The primary outcome was embryo survival rates post thawing. Results: Sixty-five patients met inclusion criteria. 145 embryos were biopsied before cryopreservation and 228 embryos were cryopreserved and biopsied after thawing. Embryo survival was significantly greater in the latter group (77% vs. 68%, p < 0.0001). Conclusion: Cryopreservation preceding biopsy results in better embryo survival compared to biopsy before cryopreservation.