Kuo-Chung Lan

Major complications associated with laparoscopic-assisted vaginal hysterectomy: ten-year experience.

STUDY OBJECTIVEnTo describe our experience with major complications associated with laparoscopic-assisted vaginal hysterectomy (LAVH) and compare our results with those of the American Association of Gynecologic Laparoscopists (AAGL) membership survey and another similar study.nnnDESIGNnRetrospective study (Canadian Task Force classification II-3).nnnSETTINGnUniversity-affiliated hospital.nnnPATIENTSnTwo thousand seven hundred two women. Intervention. LAVH.nnnMEASUREMENTS AND MAIN RESULTSnDemographic data and medical histories (age, parity, surgical indications, pathologic findings, major complications) were analyzed. Major complications were 11 bladder injuries, 4 ureter injuries, 11 bowel injuries, 2 vascular injuries, 2 cases of massive bleeding from the vaginal cuff or colpotomy wound with associated impending shock, 2 cases of postoperative ileus, and 2 pelvic abscesses. Our overall major complication rate was 1.3% compared with 2.7% in the AAGL 1995 membership survey (p <0.001). Similar rates of febrile morbidity (2.2% and 2.0%), bleeding requiring transfusion (0.05% and 0.06%), and bowel, ureteral, or bladder injury (1.0% and 1.0%) were noted between our study and the other 1995 study (all p >0.05). Of 34 major complications in our study, 24 occurred during hysterectomy performed by inexperienced general gynecologists and 10 by an experienced endoscopist (p = 0.005).nnnCONCLUSIONnThe rate of major complications associated with LAVH can be reduced when the procedure is performed by a well-trained laparoscopic surgeon compared with a less-experienced general gynecologist.

Multiple uterine angioleiomyomas in a woman presenting with severe menorrhagia

BACKGROUNDnAngioleiomyoma is a rare benign neoplasm that originates from smooth muscle cells and contains thick-walled vessels. There were only five cases of uterine angioleiomyoma reported in the available English literatures. We present here the unique computed tomography finding in a patient with multiple uterine angioleiomyomas causing severe menorrhagia.nnnCASEnA 50-year-old, nulligravid woman consulted us with the complaint of menorrhagia for 3 years and progressively palpable lower abdominal mass for a half year. Laboratory findings were all within normal limits except lower hemoglobin concentration (6.2 g/dl). An abdomino-pelvic computed tomography (CT) showed that a huge 30-cm heterogeneously multilobulate mass with solid and laminated configuration, with cystic and multiseptal contents was found in left lower abdomen and pelvic cavity. At laparotomy, the area beneath the left broad ligament was filled with a well-encapsulated, elastic, ovoid, and lobulate mass that connected to the uterus and measured up to 20 cm in greatest diameter. The uterus was composed of a huge intramural tumor and measured 28 x 21 x 12 cm. The uterus and huge subserosal tumor were resected completely and a frozen section was obtained. The final histopathologic diagnosis was angioleiomyoma, a definitely benign soft tissue tumor. Eighteen months after surgery there was no recurrence.nnnCONCLUSIONnUterine angioleiomyoma should be considered when prominent tortuous vascular-like enhancing structures are noted on CT examination of a well-demarcated soft tissue mass arising from the uterus in pelvis. Either angiomyomectomy with tumor-free margins or hysterectomy proved to be an effective treatment in these cases, and resulted in a good recovery and a satisfactory outcome.

Human oocyte maturity in vivo determines the outcome of blastocyst development in vitro

AbstractPurpose: To date, the impact of oocyte maturity at aspiration on the blastocyst formation in vitro has not been fully evaluated. This study was undertaken to assess the influence of oocyte maturity in patients undergoing in vitro fertilization and blastocyst transfer program.nMethods: A total of 1278 oocytes derived from 147-IVF cycles were retrospectivly analyzed. Oocyte maturity was graded on a scale from 1 to 5 based on the morphology of the ooplasm, cumulus mass, corona radiata, and membrana granulosa cells.nResults: Mature oocytes yielded the highest fertilization rates. Although the cleavage rates were similar in both groups, the percentage of poor morphology, day-3 embryos from the nonmature-oocyte group was significantly higher than from the mature-oocyte group (54.7% vs. 15.5%, P < 0.001). Although good morphology, day-3 embryos were collected from nonmature oocytes, the incidence of these embryos developing to the blastocyst stage was significantly less than from mature oocytes (33.3% vs. 71.2%, P < 0.001). Although blastocyst stage embryos were collected from nonmature oocytes, the incidence of these embryos developing to the top-scoring blastocysts was significantly less than from mature oocytes (58.3% vs. 89.5%, P < 0.001).nConclusions: These phenomena suggest that oocyte maturity produced in vivo determine the fertilization potential and subsequent blastocyst quality in vitro.

Increased Progesterone/Estradiol Ratio on the Day of hCG Administration Adversely Affects Success of In Vitro Fertilization–Embryo Transfer in Patients Stimulated with Gonadotropin-releasing Hormone Agonist and Recombinant Follicle-stimulating Hormone

OBJECTIVEnWe investigated the influence of premature luteinization in in vitro fertilization using a long protocol of gonadotropin-releasing hormone agonist (GnRHa) and recombinant follicle-stimulating hormone (rFSH), taking ovarian response into account in the definition of premature luteinization.nnnMATERIALS AND METHODSnA total of 339 cycles of controlled ovarian hyperstimulation with rFSH and GnRHa were performed in 311 infertile couples. Premature luteinization was defined as a progesterone (P) to estradiol (E2) ratio of > 1 on the day of human chorionic gonadotropin (hCG) administration. The P/E2 ratio is calculated as: P (ng/mL) 1,000/E2 (pg/mL). Clinical outcomes were compared for the prematurely luteinized and non-prematurely luteinized groups.nnnRESULTSnThe mean number of retrieved oocytes, recovered mature oocytes, embryos and top quality embryos were significantly higher in the non-prematurely luteinized group than in the prematurely luteinized group. Although fertilization rates and implantation rates were similar between the two groups, the clinical pregnancy rate was higher in the non-prematurely luteinized group than in the prematurely luteinized group.nnnCONCLUSIONnPremature luteinization, defined as late follicular P/E2 ratio of > 1 in long GnRHa cycles with rFSH stimulation, adversely affected ovarian responses and clinical outcomes. It seems unrelated to preovulatory luteinizing hormone (LH) elevation and LH/hCG content of gonadotropins and could be associated with poor ovarian response and the presence of dysmature follicles.

The Maturity of Human Cumulus-Free Oocytes Is Positively Related to Blastocyst Development and Viability

AbstractPurpose: We investigated whether the human oocyte maturity at the removal of cumulus/corona cells affects the embryo outcome in vitro.nMethods: A total of 620 oocytes, which subsequently underwent blastocyst culture, were included in this analysis. Oocytes that were in prophase or Metaphase I of meiosis at the removal of cumulus/corona cells were in Group II. Oocytes that were in Metaphase II at the removal of cumulus/corona cells were in Group I.nResults: Group I oocytes yielded the highest fertilization rates (96.3% vs. 77.1%, P < 0.001). The incidence of Group II oocytes developing to the blastocyst stage was significantly less than from Group I oocytes (38.1% vs. 86.1%, P < 0.001). The percentage of top-scoring blastocysts from Group I oocytes was higher than that of Group II oocytes (95.4% vs. 76.2%, P < 0.001).nConclusions: Oocyte maturity at the removal of cumulus/corona cells needs to be considered in selecting good quality blastocysts for embryo transfer.

Progesterone elevation on the day of human chorionic gonadotropin administration is not the only factor determining outcomes of in vitro fertilization

OBJECTIVEnTo assess whether progesterone elevation is the only factor in determining outcomes of in vitro fertilization (IVF).nnnDESIGNnRetrospective cohort study.nnnSETTINGnInfertility clinic at Kaohsiung Chang Gung Memorial Hospital, Taiwan.nnnPATIENT(S)nOne thousand five hundred eight women undergoing a total of 1,508 IVF cycles.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nClinical pregnancy and live-birth rates.nnnRESULT(S)nPatients were classified into four subgroups according to their progesterone concentration on the day of human chorionic gonadotropin (hCG) triggering. The clinical pregnancy and live-birth rates were statistically significantly associated with the age of the woman, the day of embryo transfer, the progesterone concentration on the day of hCG administration, the number of transferred embryos, and the number of top-quality embryos transferred. However, after omitting the women with the highest progesterone concentration (≥1.94 ng/mL), only four factors-patient age, day of embryo transfer, number of transferred embryos, and number of top-quality embryos transferred-were statistically significantly associated with the clinical pregnancy and live-birth rates.nnnCONCLUSION(S)nProgesterone concentration on the day of hCG administration is not the only factor determining the clinical pregnancy and live-birth rates. Fresh embryos from women should be frozen with extremely high progesterone concentrations. Each patients general condition and the capacity for frozen-thawed embryo transfer should be considered before implantation.

Retinoic acid influences the embryoid body formation in mouse embryonic stem cells by induction of caspase and p38 MAPK/JNK‐mediated apoptosis

Although all‐trans retinoic acid (RA), the oxidative metabolite of vitamin A, is essential for normal development, high levels are teratogenic in many species. RA results in immediate effects on the preimplantation embryo and on blastocyst development in vitro and in vivo. To further elucidate the cellular mechanisms of early postimplantation embryo development induced by RA, we present an embryonic cell line, B5, as a candidate system for the investigation of these processes. We used undifferentiated ES cells as the model, which is from the undifferentiated status to differentiated status [embryoid body (EB) formation] mimicking postimplantation embryo development (egg‐cylinder stage of embryo formation) to clarify the cellular mechanism of action of RA in the implanted blastocysts and cell apoptosis following the series of exposures to differing RA concentrations. Using an in vitro model, we identified the impact of RA on undifferentiated embryonic stem (ES) cells, including inhibition of cell proliferation and induction of cell apoptosis. JNK, P‐38 and caspase activation were shown in the nature of RA‐triggered apoptotic signaling in ES cells. The carry‐on influences of RA on the ES cell were shown in the formation of EB from the pretreated ES cells. RA resulted in apparent impact on undifferentiated ES cells in vitro, with increased numbers of apoptotic cells initially and inhibited cell proliferation, which led to decreased size of EB. The process of EB formation (mimicking the early postimplantation embryo development) is regulated by RA‐induced apoptosis through the activation of caspase and P38 MAPK/JNK pathway.

Effect of curcumin on in vitro early post-implantation stages of mouse embryo development §

OBJECTIVESnThis study was designed to examine the embryotoxic potential of the curcumin at the blastocyst stage and during early post-implantation development of mouse embryos in vitro.nnnSTUDY DESIGNnCurcumin was administered to ICR mice embryos at a dose of 0, 6, 12, 24 μM throughout in vitro culture. A total of 1015 embryos were randomly assigned to the different dosage groups. The embryotoxic effects were studied by the exposure of curcumin at the blastocyst, implanted blastocyst and early egg cylinder stages, respectively. For assessment of implantation in vitro and further embryonic differentiation, blastocysts were cultured for 8 days. The cell proliferation of outgrowth blastocysts was analysed by Giemsa staining.nnnRESULTSnExposure to 24 μM of curcumin at the implanted blastocyst stage or early egg stage cause adverse effects on development. The percentage of embryos in the later stages of development was changed depending upon the dose of curcumin used. Furthermore, exposure to 24 μM of curcumin at the blastocyst stage was lethal to all embryos. The number of nuclei per outgrowth of the blastocyst decreased significantly after curcumin pre-treatment. The percentage of trophoblastic giant cells per outgrowth increased significantly after curcumin pre-treatment.nnnCONCLUSIONSnThese findings demonstrate that curcumin exerts an adverse effect on mouse embryos during the early post-implantation stages of development, equivalent to day 3-day 8 of gestation in vivo. Curcumin treatment or administration should be used carefully at the early post-implantation stage of gestation.

Expression of inhibin-activin subunits, follistatin and smads in granulosa-luteal cells collected at oocyte retrieval.

AbstractPurpose: To examine the expression of inhibin-activin subunits, follistatin, and Smads 2, 3 and 4 in granulosa-luteal cells at the time of oocyte retrieval.n Methods: Quantitative reverse transcriptase-polymerase chain reaction was performed to quantify the mRNA expression of the investigated genes: inhibin α-subunit, inhibin-activin βA- and βB-subunits, follistatin, and Smads 2, 3 and 4.n Results: α-, βA- and βB-subunits of inhibin-activin, and follistatin were all well expressed in granulosa-luteal cells obtained from either dominant or cohort follicles. α-subunits strongly correlated with Smad2 (pxa0<xa00.001). βA-subunit significantly correlated with Smad4, pxa0<xa00.001. βB-subunit significantly correlated with Smad2, p=0.002, and follistatin expression strongly correlated with the expression of Smads 2 and 4 (pxa0<xa00.001 and = 0.007 respectively).n Conclusions: We found, for the first time that inhibin-activin βB-subunit mRNA was well expressed in human granulosa-luteal cells obtained from either dominant or cohort follicles. α-, βA- and βB-subunits and follistatin correlated with Smads to varied degrees, suggesting the active roles of the above genes at the time of oocyte retrieval.

THE INFLUENCES OF WEATHER ON PATIENTS WITH DIFFERENT OVARIAN RESPONSES IN THE TREATMENT OF ASSISTED REPRODUCTIVE TECHNOLOGY

Purpose: The purpose of this study was to evaluate the influences of tropical weather on patients with different ovarian responses in the treatment of assisted reproductive technology.Methods: Six-hundred fourty-seven women underwent their first treatment cycles were retrospectively analyzed. Patients received embryo transfer either 3 days or 5 days after oocyte retrieval, depending on the number and quality of embryos on day-2.Results: Significant correlations were demonstrated in the top quality embryo rates of day-3 and day-5 embryo transfers with temperature, humidity, and atmosphere pressure. The cumulative light hours negatively correlated with the implantation and pregnancy rates of day-3 embryo transfer (−.282 and −.282, respectively), while they positively correlated with those of day-5 embryo transfer (.225 and .224, respectively).Conclusions: These results clearly suggest that weather may exert influences on the outcome of assisted reproductive technology. Patients with different ovarian responses or blastocyst culture and transfer may modify weather influences.