Shinichiro Wada

Macrophage migration inhibitory factor in the human ovary: Presence in the follicular fluids and production by granulosa cells

Cytokines play an important role in ovarian function. We unexpectedly found high expression of macrophage migration inhibitory factor (MIF) mRNA in human ovarian tissues. Hence, we examined the presence of MIF in the follicular fluid because the follicular microenvironment is important for oocyte fecundity. The follicular fluids were collected from ovaries of patients undergoing in vitro fertilization and embryo transfer. A higher amount of MIF was identified in the follicular fluid, 80.3 ± 4.6 ng/ml (mean ± SE), in which the concentration was significantly decreased as the size of the follicles increased. To detect MIF mRNA expression in the granulosa cells, reverse transcription‐polymerase chain reaction was carried out and this showed an amplified transcript specific for MIF. Furthermore, the presence of MIF protein in the granulosa cells was confirmed by Western blot analysis. These results suggest the possibility that MIF mediates various immunological events in the process of oocyte development.

Tubal pregnancy in a unicornuate uterus with rudimentary horn: a case report

OBJECTIVE To report a case of tubal pregnancy in a unicornuate uterus with rudimentary horn on the side of the rudiment and its pathology. DESIGN Case report. SETTING University hospital. PATIENT An 18-year-old woman, primigravida, with tubal pregnancy. INTERVENTION(S) Systemic administration of methotrexate, salpingectomy by laparotomy, and laparoscopic surgery for resection of rudimentary horn. MAIN OUTCOME MEASURE(S) Emergent laparotomy revealed that the intraperitoneal hemorrhage was caused by the rupture of the tubal pregnancy on the same side as the rudimentary horn of the unicornuate uterus. A corpus luteum was found at the ipsilateral ovary of the rudimentary horn. RESULT(S) Image diagnosis and pathological examination of the rudimentary horn revealed that this uterine malformation was a unicornuate uterus with a noncommunicated, noncavitary rudimentary horn, corresponding to class IIc of the American Fertility Society classification of müllerian anomalies. CONCLUSION(S) This is the first report of a tubal pregnancy on the side of the noncommunicating rudimentary horn with the ipsilateral ovary carrying a corpus luteum in a unicornuate uterus.

Uterine Vein Rupture at Delivery as a Delayed Consequence of Laparoscopic Surgery for Endometriosis: A Case Report

Laparoscopic resection of deep infiltrating endometriosis (DIE) has been reported to be an effective method for reduction of endometriosis-associated pain. As its complications, bowel perforation, urinary tract injury and neurogenic bladder are well known; however, uterine vein rupture during pregnancy has not been reported previously. We encountered a case of hemoperitoneum resulting from uterine vein rupture at a delivery as a delayed consequence of laparoscopic resection of DIE. A 31-year-old, para 2 woman underwent laparoscopic resection of lateral pelvic peritoneum, uterosacral ligaments, and bilateral endometriomas, exposing uterine vessels, which we covered with fibrin glue. Endometriosis-associated pain disappeared, and then the patient conceived 4 months later. The course of pregnancy and induction of labor with controlled oxytocin infusion was uneventful, and the patient delivered a female baby without asphyxia. Immediately after delivery, low abdominal pain with hypotension occurred despite absence of abnormal vaginal bleeding. Ultrasonography and the blood hemoglobin value suggested hemorrhagic shock owing to hemoperitoneum; therefore emergency exploratory laparotomy was performed. Active bleeding was found at the right uterine vein, which was then sutured for hemostasis. The patient received a blood transfusion and recovered without any problems. The bleeding lesion was located at the vein on which the peritoneum had been removed at the first laparoscopy, which suggested that the operation for DIE included a risk of uterine vessel rupture during pregnancy.

Reversal of Intra-AmnioticChlamydia trachomatis Ant igen Status

Chlamydia trachomatis (CT) infection in pregnant women is related to unfavorable obstetric outcomes such as prematurity, intrauterine growth retardation, and stillbirth. A 22-year-old woman underwent transabdominal amniocentesis at 16 weeks of gestation (GW). A CT antigen test using polymerase chain reaction in the amniotic fluid was found to be positive, though the patient had no symptom of infection. Beginning at 20 GW, clarithromycin was orally administered at a dose of 400 mg/day for 2 weeks. The CT antigen test in amniotic fluid at 28 GW turned to a negative result. A female baby was vaginally born at 38 GW by spontaneous labor. The CT antigen test of her gastric contents showed a negative result and anti-CT IgM in umbilical cord blood was negative. Neither respiratory distress, pneumonia, nor conjunctivitis was detected. To the best of our knowledge, this case is the first report showing the reversal of the intra-amniotic CT antigen status by antibiotic treatment.

Successful treatment of uterine artery pseudoaneurysm with laparoscopic temporary clamping of bilateral uterine arteries, followed by hysteroscopic surgery

Surgical strategies for the treatment of uterine artery pseudoaneurysm (UAP) include transarterial embolization and ultrasound‐guided low‐dose thrombin injection. Such strategies, however, have limitations and include the risk of ischemic damage to the uterus. We report a case of UAP treated with a new hysteroscopic and laparoscopic technique. A 29‐year‐old G1P0 woman with spontaneous abortion was transferred to the present institution because of hemorrhagic shock. We diagnosed ruptured UAP on transvaginal ultrasound with color Doppler. Emergency laparoscopic temporary clamping of the bilateral uterine arteries was done to reduce the bleeding, and transcervical resection to stop the hemorrhaging and to collect the pseudoaneurysm tissue. After surgery, blood flow to the myometrium was monitored on ultrasound. By postoperative day 48, normal menstruation had restarted, and no intrauterine adhesions were observed. On pathology of the UAP, a dilated spiral artery without its characteristic elastic fibers was identified. This surgical approach may help preserve fertility and allow for pathological diagnosis of UAP.

Proteolytic Activation of Single-chain Tissue-type Plasminogen Activator by Protease/α2-Macroglobulin Complex Isolated from Human Ovarian Follicular Fluid

Abstract α2-Macroglobulin is a high-molecular-weight glycoprotein that inhibits a variety of endoproteases. Proteolytic enzymes associated with this inhibitor are thought to be unable to act on protein substrates. This paper reports that the α2-macroglobulin fraction isolated from the follicular fluid of human ovaries is capable of proteolytically activating human single-chain tissue-type plasminogen activator. We demonstrated that a bound protease unlike plasma kallikrein was involved in the activation. This activity was maximally detected at pH values in the ranges 6–9, and was strongly inhibited by diisopropylfluorophosphate and aprotinin, indicating that the enzyme responsible for the activation is a serine protease. In summary, this paper describes for the first time that a protease complexed with α2-macroglobulin exhibits detectable proteolytic activity toward the protein substrate single-chain tissue-type plasminogen activator.

Recovery of quality of life after laparoscopic myomectomy

It is commonly thought that laparoscopic surgery leads to faster postoperative recovery for its low invasiveness. We evaluated postoperative quality of life (QOL) after laparoscopic myomectomy (LM) by using the Euro‐QOL 5 dimension (EQ‐5D) score and analyzed its relationship to surgical factors.

Complications Related to the Initial Trocar Insertion of Three Different Techniques: A Systematic Review and Meta-Analysis

This systematic review aimed to investigate complications related to initial trocar insertion among 3 different laparoscopic techniques: Veress needle (VN) entry, direct trocar entry (DTE), and open entry (OE). A literature search was completed, and complications were assessed. Major vessel injury, gastrointestinal injury, and solid organ injury were defined as major complications. Minor complications were defined as subcutaneous emphysema, extraperitoneal insufflation, omental emphysema, trocar site bleeding, and trocar site infection. Arm-based network meta-analyses were performed to identify the differences in complications among the 3 techniques. Seventeen studies were included in the quantitative analysis. DTE resulted in fewer major complications when compared with VN entry although the difference was not significant (p = .23) as well as significantly fewer minor complications (p < .001). There were no significant differences in minor complications when comparing OE and DTE (p = .74). Fewer major complications were observed with OE compared with VN entry although the difference was not significant (p = .31). There were significantly fewer minor complications for patients who underwent OE (p = .01). DTE patients experienced the least number of minor complications followed by VN entry and OE. In conclusion, major complications are extremely rare, and all 3 insertion methods can be performed without mortality.

Magnetic Resonance Imaging Grading System for Preoperative Diagnosis of Leiomyomas and Uterine Smooth Muscle Tumors

STUDY OBJECTIVE To evaluate a new magnetic resonance imaging (MRI) grading system for preoperative differentiation between benign and variant-type uterine leiomyomas including smooth muscle tumors of uncertain malignant potential (STUMPs). DESIGN Retrospective analysis (Canadian Task Force classification III). SETTING Teaching hospital (Teine Keijinkai Hospital). PATIENTS Three-hundred thirteen patient medical records were retrospectively reviewed if treated for uterine myomas and diagnosed with variant type leiomyomas or STUMPs (n = 27) or benign, typical leiomyomas (n = 286) and treated between January 2012 and December 2014. INTERVENTION Uterine myoma classifications using MRI findings according to a 5-grade system (grades I-V) based on 3 elements. MEASUREMENTS AND MAIN RESULTS Uterine myoma MRI classifications were based on 3 elements: T2-weighted imaging (high or low), diffusion-weighted imaging (high or low), and apparent diffusion coefficient values (high or low; apparent diffusion coefficient < 1.5 × 10-3 mm2/sec was considered low). Grades I to II were designated as typical or benign leiomyomas, grade III as degenerated leiomyomas, and grades IV to V as variant type leiomyomas or STUMPs. Accuracy levels were 98.9%, 100%, 94.3%, 58.8%, and 41.9% for grades I through V lesions, respectively. The grades were divided into 2 groups to discriminate benign leiomyomas and STUMPs (grades I-III were considered negative and grades IV-V positive). Grades IV to V scored 85.2% for sensitivity, 91.3% for specificity, 47.9% positive predictive value, 98.5% negative predictive value, a 9.745 positive likelihood ratio, and a .162 negative likelihood ratio. CONCLUSION This novel MRI grading system for uterine myomas may be beneficial in differentiating benign leiomyomas from STUMPs or variant type leiomyomas and could be a future effective presurgical assessment tool.