Jothi Kumar

Pulmonary metastases in gestational trophoblastic disease: a review of 97 cases

Summary. Metastatic gestational trophoblastic disease poses problems in diagnosis and management and has a poorer prognosis than the nonmetastatic variant. The lung is the most common site of metastases. This paper reviews 97 patients with pulmonary metastasis developing after gestational trophoblastic disease who were seen at one centre over 26 years. Most patients had an antecedent molar pregnancy but an associated choriocarcinomatous lesion in the uterus was absent in the majority. In many patients the pulmonary lesion was asymptomatic. Whilst chemotherapy was the treatment of choice, selective thoracotomy in cases with solitary lung nodules reduced the treatment time and need for aggressive multi‐drug combination regimens. The overall survival rate at 2 years after diagnosis was 65%. A higher mortality was found when the antecedent pregnancy ended at term, when the time interval between the preceding pregnancy and diagnosis of pulmonary metastases was > 1 year, when multiple pulmonary secondaries were present or when cerebral metastases occurred. The main causes of death were cerebral haemorrhage, respiratory failure and pulmonary embolism.

Ovarian hyperstimulation syndrome is associated with reversible impairment of vascular reactivity

OBJECTIVE To determine if there is a loss of normal peripheral arteriolar vasoconstrictor reactivity in women with severe ovarian hyperstimulation syndrome (OHSS). SETTING Prospective controlled study. DESIGN National University Hospital, Singapore. PATIENT(S) Forty-three women undergoing treatment in an IVF program: 22 women with severe OHSS and 21 normal women without OHSS. INTERVENTION(S) Measurement and quantification of the cutaneous arteriolar vasoconstrictor response using laser Doppler fluximetry. MAIN OUTCOME MEASURE(S) Changes in blood flow as an index of vasoconstrictor response before and after treatment for OHSS with albumin. RESULT(S) The mean (+/-SE) percentage (%) change in normal control women was -68.3% +/- 4.7. This was significantly different from women with OHSS (-32.3% +/- 11.1). The response in women with OHSS changed significantly after treatment with IV albumin (-60.4% +/- 5.7) and was no different than the control response. The reproducibility of the technique was -13.6% (+/-2.8). CONCLUSION(S) Women with OHSS have impaired vascular reactivity when compared with normal women.

Premature condensation of chromatin induced in goat (Capra hircus) oocytes after gonadotrophin treatment

In comparison with ovine follicle stimulating hormone (FSH), superovulation of goats with pregnant mare serum gonadotrophin (PMSG) produced premature ovulations within 48 h of drug administration. To test the hypothesis that this may be associated with a differential effect of the two drugs on oocyte maturation, we have compared the meiotic status of oocytes obtained at three different time intervals from animals treated with 1200 i.u. PMSG or 12 mg ovine FSH and from untreated control animals. Significantly more oocytes from PMSG-treated, compared with control and FSH-treated, animals showed premature condensation of chromatin at both the time of sponge withdrawal and 20 h later. The chromatin condensation was, however, not associated with germinal vesicle breakdown. In contrast, when oocytes were examined 6 h before the expected time of ovulation following human chorionic gonadotrophin (hCG) injection, no significant difference was found in the proportion of oocytes undergoing germinal vesicle breakdown between the three treatment groups, with most oocytes being at the metaphase I or II stage of meiosis. We conclude that superovulation of goats with PMSG at a dose resulting in a high incidence of premature ovulations is associated with premature activation of the initial stages of nuclear maturation in oocytes. In contrast, although treatment with 12 mg ovine FSH did not cause premature ovulations, it was not totally devoid of premature chromatin-condensing activity in oocytes.

Treatment of infertility associated with endometriosis

Endometriosis is a condition in women where glandular and stromal endometrial tissue are present outside the uterus. It is found most frequently in the pelvic cavity, and affects mainly the ovaries and pelvic visceral peritoneum. It is estimated that 3-10% of all women in the reproductive age group have endometriosis, whilst amongst those presenting with infertility or pelvic pain, the reported incidence ranges from 20 to 90%. ~3 Indeed, the association between endometriosis and infertility has long been recognized, with early studies suggesting that 25--50% of infertile women have endometriosis, whilst 30-50% of women with endometriosis are infertile. 4,5 Strathy et al. (1982) 6 reported in a prospective study that there was a higher incidence of endometriosis in infertile women compared with fertile women undergoing tubal ligation. Other retrospective studies have similarly shown that infertile women are 10-20 times more likely to have endometriosis than fertile women. 7,8 Current evidence, therefore, suggests a strong association between endometriosis and infertility. However, to date, there is no convincing proof that endometriosis directly causes infertility, except perhaps when it leads to gross anatomic distortion of the pelvis, ovaries or tubes. It is important to keep this in mind when discussing the management options available for the treatment of endometriosis-related infertility. This is particularly relevant when pregnancy outcome, following treatment of minimal and mild degree endometriosis, is concerned. Here, consider-

Chronic low-dose follicle-stimulating hormone compared with clomiphene/human menopausal gonadotropin for induction of ovulation

Concurrent administration of clomiphene can reduce the amount of gonadotropins required for induction of ovulation. Recently, follicle-stimulating hormone (FSH) administered in a chronic, low-dose fashion has been reported to give satisfactory pregnancy rates. We compared the conventional clomiphene/human menopausal gonadotropin (hMG) with the chronic, low-dose FSH regimen for induction of ovulation in 87 patients over 110 cycles. The clomiphene/hMG regimen required half the amount of gonadotropin compared to the chronic FSH regimen to achieve follicular maturation. Despite the reduced amount of gonadotropin, the clomiphene/hMG regimen induced a mean fourfold higher level of estradiol production and was associated with significantly greater numbers of large and intermediate-sized follicles compared to the chronic FSH regimen. The proportion of clomiphene/hMG cases with multifollicular development and overstimulation was therefore high (30%). In contrast, the chronic FSH regimen, despite requiring larger amounts of gonadotropin and longer periods of treatment, resulted in unifollicular development, low rates of overstimulation and improved pregnancy rates. We conclude that although clomiphene can reduce the requirement for gonadotropins, the relative safety and effectiveness of the chronic low-dose FSH regimen makes it the method of choice for ovulation induction.

In vitro fertilization outcome in severe ovarian hyperstimulation syndrome: An age-matched contemporaneous control study

AimOvarian hyperstimulation syndrome (OHSS) is a potentially life-threatening, iatrogenic complication of assisted reproduction and has been associated with poor in vitro fertilization outcome. The aim of the present study was to evaluate the pregnancy rate and outcome following severe OHSS, at a single center over a three-year period.MethodsThe incidence of severe OHSS at the IVF Center, National University of Singapore, in Singapore, was 4% (48 cases over 1200 cycles) during the period of 1997–2000. The present retrospective study compared 48 cases of severe OHSS to 144 age-matched, contemporaneous controls without OHSS.ResultsThe total gonadotropin required for severe OHSS group was found to be lower than for that of controls (2664.06 ±768.29 IU vs 3349.58 ±2003.73 IU), although duration of stimulation was similar. The OHSS group was associated with a fivefold increase (OR 5.293, 95% CI: 2.116-13.238) in pregnancy rate compared to controls (87.5% vs 56.9%; P< 0.05). Late OHSS was more common (38/48 cases) and had a pregnancy rate of 97% per embryo transfer. There was no significant difference in the multiple pregnancy (54% vs 48%; P> 0.05) and miscarriage rates (14% vs 7.3%; P > 0.05) between the groups.ConclusionSevere OHSS at our center were mostly late onset. The pregnancy rate was significantly higher, but multiple pregnancy and miscarriage rates were not significantly increased when compared to the age-matched contemporaneous controls.

The First 2 Case Reports of Frozen Embryo Donation Twin Pregnancies in Singapore: Hormonal Profiles and Obstetrical Outcome

A 35‐year‐old woman with premature ovarian failure and another 30‐year‐old woman with gonadal dysgenesis were the recepients of donated supernumerous frozen embryos after successfully prepared with cyclic steroid replacement therapy as described previously.1,2)

Responses of polycystic ovarian syndrome and related variants to low-dose follicle stimulating hormone

Objective: To determine whether patients with classical polycystic ovarian syndrome (PCOS) respond differently to low‐dose FSH therapy in comparison with anovulatory patients (PCOS‐like) where only some features of PCOS are present. Methods: Two groups of patients were studied. The PCOS group (25 patients, 51 cycles) and the PCOS‐like group (38 patients, 57 cycles) were treated with the same protocol of purified FSH, commencing with an initial dosage of 75 IU/day and increasing by 37.5 IU/day after 14 days, where necessary. Estradiol levels and ultrasonographic evidence of follicular development were used for monitoring. Results: PCOS patients required more ampules of FSH, needed more days of gonadotropin stimulation, secreted higher levels of E2 and had increased numbers of intermediate follicles compared to the PCOS‐like group. Conclusions: This study demonstrated significant differences between PCOS and other PCOS‐like conditions when treated with low‐dose FSH. Classification of the subvariants of PCOS may have therapeutic implications.

ART practice in Singapore

ConclusionsART practice in Singapore is monitored by the MOH, with guidance from an Advisory Committee on HRE. All centers and practitioners must be licensed. Data collection is by means of three forms. Based on the submissions, the averages for all centers in Singapore for the 5 years 1990 to 1995 were as follows: clinical pregnancies averaged 16.4% per cycle and 22.6% per replacement, and take-home baby rates averaged 11.5% per cycle and 15.9% per replacement.

Pulmonary metastases in gestational trophoblastic disease: A review of 97 cases

Pab&gid progoadk iodkators In CerviaI cancer with partkWrefeaatopatIatsunderthe~eof40years Buckley CH; Beards CS; Fox H Department of Pathology, University of Manrester, Manchester Ml3 9PL; UK British Journal of Obstetrics and Gynaecology/95/1 (4756)/1988/ The presence of lymph mode metastases in patients with cervical cancer is an important predictor of death and recurrence of disease. Lymph node metastases are more common in patients with mucus-secreting carcinomas than in women with pure squamous carcinomas even in what appears, clinically, to be early stage disease: such neoplasm6 are more frequent in women under the age of 40 years. The recognition of mucus secretion in a carcinoma and the detection of vascular permeation adjacent to the primary neoplasm identifies the patient at greatest risk of having pelvic lymph node metastases.