Kozue Asato

Endometriosis and pregnancy outcome: are pregnancies complicated by endometriosis a high-risk group?

OBJECTIVES Increased incidence of preterm birth, pregnancy-induced hypertension (PIH) and small-for-gestational-age (SGA) babies have been reported in women with endometriosis, but the study populations included women in whom a definitive diagnosis was not attainable, and women who conceived via in vitro fertilization/embryo transfer (IVF/ET), which, in itself, is a risk factor for adverse pregnancy outcome. Thus there is a lack of consensus on the effects of endometriosis on pregnancy outcome. This study compared the pregnancy outcomes of women with or without a definitive diagnosis of endometriosis on laparoscopy. STUDY DESIGN Retrospective comparison of pregnancy outcomes of 108 women who underwent managed delivery of pregnancies established after laparoscopic investigation of infertility. Women with factors known to affect pregnancy outcome, such as age ≥41 years, conception via IVF/ET and multiple births, were excluded. Forty-nine of the study participants had endometriosis (En+ group) and 59 participants did not have endometriosis (En- group). RESULTS There were no significant differences in mean (±standard deviation) age (33±3.8 vs 33.6±4.1 years), history of miscarriage, history of preterm birth and history of PIH between the two groups. Ovulation induction was used for infertility treatment in 26.5% of the En+ group and 30.5% of the En- group, and artificial insemination was used in 30.6% of the En+ group and 32.2% of the En- group. Regarding pregnancy outcomes, no significant differences in miscarriage (18.4% vs 18.6%), subchorionic haematoma (5.0% vs 2.1%), preterm birth (7.5% vs 8.3%), PIH (15.0% vs 12.5%), caesarean section (32.5% vs 22.9%), gestational age at delivery (38.9±1.5 vs 38.8±1.7 weeks), birth weight (3013.3±480 vs 2934.5±639.5g) and SGA babies (2.5% vs 2.1%) were found between the En+ and En- groups. Placental abruption did not occur in either group. One neonate had trisomy 21 in the En+ group, and one woman had gestational diabetes in the En- group. CONCLUSION Endometriosis may not affect pregnancy outcome, but there is a need for a large prospective study.

Hysteroscopic tubal catheterization under laparoscopy for proximal tubal obstruction.

PurposeThe purpose of this study was to investigate the fertility outcomes of infertile patients having proximal tubal obstruction treated with hysteroscopic tubal catheterization (HCT) for recanalization under diagnostic laparoscopy.MethodsFrom January 2000 to December 2008, diagnostic laparoscopy was used to assess the tubal status of 61 patients with unilateral or bilateral proximal tubal obstruction, as confirmed by hysterosalpingography. Among them, 35 patients with tubal obstruction confirmed by chromopertubation under laparoscopy subsequently underwent HCT. The pregnancy outcomes and success rates of recanalization were investigated.ResultsIn the 35 patients with confirmed tubal obstruction, HCT was performed in 54 fallopian tubes. The success rate of recanalization was 25.9% (14/54) per tube and 37.1% (13/35) per patient. Of the patients in whom tubal patency was restored, 4 achieved pregnancy, including 1 tubal pregnancy and 1 miscarriage. Among the 61 patients, excluding 14 who underwent in vitro fertilization–embryo transfer (IVF–ET) after laparoscopy, 13 were pregnant (27.7%), 9 gave live births, 1 had tubal pregnancy, and 3 had miscarriages.ConclusionsHCT under laparoscopy is an option for couples with tubal infertility who do not prefer IVF–ET.

Subchorionic hematoma occurs more frequently in in vitro fertilization pregnancy.

OBJECTIVE Obstetric complications occur more frequently in pregnancies after in vitro fertilization (IVF). We attempted to determine the correlation between subchorionic hematoma and IVF pregnancies. STUDY DESIGN We analyzed 194 pregnancies achieved by infertility treatment between January 2008 and February 2012 at our hospital. Among these, 67 were achieved by IVF and 127 by non-IVF approaches. We compared the frequency of subchorionic hematoma between the groups and examined the risk factors for subchorionic hematoma in the IVF group. RESULTS No significant differences regarding age and the number of uterine surgery were observed between the groups. The duration of infertility was longer, parity and the rate of luteal support were higher in the IVF group compared with that in the non-IVF group. The frequency of subchorionic hematoma was significantly higher in the IVF group (22.4%) than that in the non-IVF group (11%) (P=0.035). Univariate analysis in the IVF group demonstrated that frozen-thawed embryo transfer (OR, 6.18; 95% CI, 1.7-22.4), parity≥1 (OR, 3.67; 95% CI, 1.0-13.2) and blastocyst transfer (OR, 3.75; 95% CI, 1.1-13.3) were risk factors for the subchorionic hematoma. CONCLUSION The frequency of subchorionic hematoma is high in IVF pregnancies, and frozen-thawed embryo transfer, parity≥1, and blastocyst transfer may contribute to subchorionic hematoma onset.

Comparison between the gonadotropin-releasing hormone antagonist protocol and the gonadotropin-releasing hormone agonist long protocol for controlled ovarian hyperstimulation in the first in vitro fertilization–embryo transfer cycle in an unspecified population of infertile couples

PurposeWe aimed to compare the efficacy of a gonadotropin-releasing hormone (GnRH) antagonist protocol and a GnRH agonist long protocol used in the first in vitro fertilization–embryo transfer (IVF–ET) cycle in an unspecified population of infertile couples.MethodsFifty and 34 patients were treated with a GnRH agonist long protocol (agonist group) and GnRH antagonist protocol (antagonist group), respectively, in the first treatment cycle. The primary and secondary outcome measures were cumulative live birth rates after fresh and cryopreserved–thawed ETs and incidence of grades II and III ovarian hyperstimulation syndrome (OHSS), respectively.ResultsNo significant differences were observed in clinical pregnancy rates (38.0 vs. 32.4%) and live birth rates (22.0 vs. 23.5%), which included both fresh and cryopreserved–thawed ETs, between the 2 groups. However, the incidence of grade III OHSS was significantly lower with the GnRH antagonist protocol than the GnRH agonist long protocol.ConclusionsUsed in the first IVF–ET cycle in an unspecified population of infertile patients, the GnRH antagonist protocol showed the same clinical outcome as the GnRH agonist long protocol.

Metastatic placental site trophoblastic tumour successfully treated with hysterectomy and EMA/CO chemotherapy

(Enzinger and Smith 1976). Preoperative diagnosis may be difficult but MRI appearances have previously been described (Craven et al. 1992; Kehagias et al. 1999). The use of multiple immunohistochemical stains is generally needed to establish a diagnosis (Espat et al. 2002). At the time of diagnosis, haemangiopericytoma was a distinct histopathological entity but now is preferably recognised as a subtype of solitary fibrous tumour (Gengler and Guillou 2006). Complete excision with adequate margins remains the treatment of choice but is usually complicated by bleeding because of the close proximity of dilated vascular beds (Enzinger and Smith 1976). Vascular embolisation may reduce the risk of bleeding during surgery (Craven et al. 1992; Dozois et al. 2009). A favourable clinical benefit was observed with sunitinib, an oral VEGFR, and PDGFR kinase inhibitor (Mulamalla et al 2008). Radiotherapy has been used as adjuvant therapy for aggressive tumours, inadequate resection margins and recurrences (Craven et al. 1992; Staples et al. 1990; Chakrabarti et al. 2009). Chemotherapy using Adriamycin alone or in combination regimens against recurrent or unresectable disease can achieve palliation (Wong et al. 1978; Beadle et al. 1983). This disease in the pelvis is best managed by a multidisciplinary team, which should include an interventional radiologist, gynaecological oncologist, radiation oncologist, medical oncologist and a colorectal surgeon. Long-term prognosis is difficult to predict as most available information is based on case reports or case series that include different sites due to the rarity of this disease. However, prolonged survival is uncommon in the presence of a large tumour burden. Disease recurrences may occur after long periods of disease-free time even up to 17 years (Begum et al. 2002). Local recurrence preceded metastasis in more than two-thirds of the patients with evidence of metastasis. The 10-year survival rate has been reported at 70 per cent (Enzinger and Smith 1976). Therefore, patients who survive should be followed for long periods.