Yuh-Ming Hwu

Poor Response of Ovaries with Endometrioma Previously Treated with Cystectomy to Controlled Ovarian Hyperstimulation

AbstractPurpose: To compare ovarian response to controlled ovarian hyperstimulation (COH) between normal ovaries and ovaries previously treated surgically for unilateral ovarian endometrioma. Methods: From January 1996 to December 2001, 32 patients with unilateral ovarian endometrioma previously treated surgically underwent 38 cycles of COH. Their records were reviewed retrospectively. The number of dominant follicles observed on the day of hCG injection and the number of eggs retrieved from the diseased and the normal ovaries in each patient were compared. Results: The numbers of dominant follicles from diseased and normal ovaries were 1.9 ±1.5 and 3.3 ± 2.1, respectively (P < 0.001). During ovum pick up, the numbers of eggs retrieved from diseased and normal ovaries were 2.9 ± 2.6 and 6.1 ± 4.1, respectively (P < 0.0001). For diseased ovaries, 21.1% (8/38) had no dominant follicles, while only 7.9% (3/38) of normal ovaries lacked dominant follicles. The clinical pregnancy rate and the implantation rate per embryo transfer were 33.3 and 17.6%. Conclusions: Surgery for ovarian endometrioma may damage ovarian reserve. It potentially results in poor ovarian response to COH, compared to the response of the contralateral normal ovary in the same individual.

Parallel vertical compression sutures: a technique to control bleeding from placenta praevia or accreta during caesarean section

Fourteen women with placenta praevia (including one who also had placenta accreta) undergoing caesarean section had massive bleeding after removal of the placenta. In order to preserve the uterus, two parallel vertical compression sutures were placed in the lower segment to compress the anterior and posterior walls of the lower uterine segment. The haemorrhage from the lower segment stopped immediately after the knots were tightened. All women later resumed normal menstrual flow with no apparent complications. Two of the 14 women had a spontaneous pregnancy one to two years after the operation. This parallel vertical compression suturing technique is simple, easy and effective for controlling bleeding in women with placenta praevia or accreta. We suggest that this technique be tried first before other more complex procedures are undertaken.

The autonomous notch signal pathway is activated by baicalin and baicalein but is suppressed by niclosamide in K562 cells

The Notch signaling pathway plays important roles in a variety of cellular processes. Aberrant transduction of Notch signaling contributes to many diseases and cancers in humans. The Notch receptor intracellular domain, the activated form of Notch receptor, is extremely difficult to detect in normal cells. However, it can activate signaling at very low protein concentration to elicit its biological effects. In the present study, a cell based luciferase reporter gene assay was established in K562 cells to screen drugs which could modulate the endogenous CBF1‐dependent Notch signal pathway. Using this system, we found that the luciferase activity of CBF1‐dependent reporter gene was activated by baicalin and baicalein but suppressed by niclosamide in both dose‐ and time‐dependent manners. Treatment with these drugs modulated endogenous Notch signaling and affected mRNA expression levels of Notch1 receptor and Notch target genes in K562 cells. Additionally, erythroid differentiation of K562 cells was suppressed by baicalin and baicalein yet was promoted by niclosamide. Colony‐forming ability in soft agar was decreased after treatment with baicalin and baicalein, but was not affected in the presence of niclosamide. Thus, modulation of Notch signaling after treatment with any of these three drugs may affect tumorigenesis of K562 cells suggesting that these drugs may have therapeutic potential for those tumors associated with Notch signaling. Taken together, this system could be beneficial for screening of drugs with potential to treat Notch signal pathway‐associated diseases. J. Cell. Biochem. 106: 682–692, 2009.

The impact of endometrioma and laparoscopic cystectomy on serum anti-Müllerian hormone levels

BackgroundSerum anti-Müllerian hormone (AMH) had been proposed as a marker of ovarian reserve. The aim of this study was to evaluate the impact of endometrioma and laparoscopic cystectomy on ovarian reserve as measured by serum AMH levels.MethodsA total of 1,642 patients were recruited in this retrospective analysis. Control group (group 1) included 1,323 infertility patients without endometrioma. Endometrioma group (group 2) included 141 patients with ovarian endometrioma. Previous cystectomy group (group 3) included 147 patients who underwent unilateral or bilateral laparoscopic cystectomy due to ovarian endometrioma more than 6 months before enrollment. Current cystectomy group (group 4) included 31 patients who underwent cystectomy during study period. Serum anti-müllerian hormone (AMH) levels were measured upon enrollment with all patients. For patients in group 4, AMH levels were measured before and 3 months after cystectomy.ResultsMean AMH level of patients in control group was significantly higher than that of endometrioma group or previous cystectomy group in each age subgroup, while the mean serum AMH level of the endometrioma group was also significantly higher than that of the previous cystectomy group in each age subgroup. The mean AMH level was significantly lower in patients with previous bilateral cystectomy compared to that of patients with unilateral cystectomy. The mean serum AMH level was also significantly lower in patients with bilateral endometrioma compared to that of patients with unilateral endometrioma. In group 4, mean AMH level significantly decreased from 3.95 +/- 0.42 preoperation to 2.01 +/- 0.21 ng/ml at 3-month postoperation.ConclusionsBoth ovarian endometrioma and cystectomy are associated with a significant reduction on ovarian reserve. Bilateral endometrioma exerts a more profound negative impact on ovarian reserve than unilateral endometrioma, regardless of either conservative or surgical intervention.

Dual trigger with combination of gonadotropin-releasing hormone agonist and human chorionic gonadotropin significantly improves the live-birth rate for normal responders in GnRH-antagonist cycles

OBJECTIVE To investigate whether dual triggering of final oocyte maturation with a combination of gonadotropin-releasing hormone (GnRH) agonist and human chorionic gonadotropin (hCG) can improve the live-birth rate for normal responders in GnRH-antagonist in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) cycles. DESIGN Retrospective cohort study. SETTING Infertility unit of a university-affiliated medical center. PATIENT(S) Normal responders to controlled ovarian hyperstimulation who were undergoing IVF-ICSI with a GnRH antagonist protocol. INTERVENTION(S) Standard dosage of hCG trigger (6,500 IU of recombinant hCG) versus dual trigger (0.2 mg of triptorelin and 6,500 IU of recombinant hCG). MAIN OUTCOME MEASURE(S) Live-birth, clinical pregnancy, and implantation rates per cycle. RESULT(S) A total of 376 patients with 378 completed cycles with embryo transfer were enrolled (hCG trigger/control group: n = 187; dual trigger/study group: n = 191). The dual trigger group demonstrated statistically significantly higher implantation (29.6% vs. 18.4%), clinical pregnancy (50.7% vs. 40.1%), and live-birth (41.3% vs. 30.4%) rates as compared with the hCG trigger group. There was no statistically significant difference in terms of patient demographics, cycle parameters, or embryo quality. CONCLUSION(S) Dual trigger of final oocyte maturation with a GnRH-agonist and a standard dosage of hCG in normal responders statistically significantly improves implantation, clinical pregnancy, and live-birth rates in GnRH-antagonist IVF cycles.

Ultra-short metformin pretreatment for clomiphene citrate-resistant polycystic ovary syndrome

Objective: To evaluate the effect of ultra‐short (12 days) metformin pretreatment in clomiphene‐citrate (CC) resistant polycystic ovary syndrome (PCOS). Method: Eighty women with CC‐resistant PCOS were randomly allocated to metformin pretreatment or usual treatment. Forty women received 1500 mg metformin daily for 12 days, followed by clomiphene 150 mg daily for 5 days along with metformin. Forty women (control group) received the same dose of clomiphene but no metformin pretreatment. Results: In the metformin group, 17 (42.5%) women ovulated, and 6 (15%) conceived. In the control group, 5 (12.5%) women ovulated but none conceived. Compared with the control group, the metformin group had significantly higher ovulation (P = 0.03) and pregnancy rates (P = 0.026). Conclusion: Twelve days of metformin pretreatment improves ovulation and pregnancy rates in women with CC‐resistant PCOS.

Conservative treatment of caesarean scar pregnancy with transvaginal needle aspiration of the embryo.

A 40 year old woman, gravida 3, para 2, was referred at six weeks of gestation for a suspected ectopic pregnancy. She had previously undergone lower segment caesarean section twice. Pelvic examination revealed a normal cervix and a normal-sized uterus with no adnexal mass. Transvaginal ultrasound examination showed that both the uterine cavity and cervical canal were empty, and a gestational sac containing a viable fetus with cardiac activity was implanted in the anterior wall of the uterus at the level of the isthmus. The thickness of the uterine wall between the bladder and gestational sac was diminished in comparison with the adjacent uterine wall. The crown–rump length of the fetus was 3.8 mm. The serum human chorionic gonadotropin (hCG) level was 12,755 miu/mL. Colour Doppler ultrasound showed abundant blood vessels distributed around the gestational sac. These findings were consistent with a diagnosis of caesarean scar pregnancy. The patient was treated with systemic intramuscular methotrexate (four doses of methotrexate 1 mg/kg on alternating each day with folinic acid). A small amount of vaginal bleeding was noted on day 4 after the second dose of methotrexate. The hCG level increased to 23,746 miu/mL and ultrasound examination continued to show a viable fetus with heart motion. The crown–rump length had increased to 6.5 mm. We decided to interrupt the pregnancy rapidly by transvaginal ultrasound-guided aspiration of the fetus. Under general anaesthesia, the vagina was cleaned and a 16-gauge double-lumen ovum aspiration needle (K-OPSD-1635-A-L, Cook, Australia) was connected to an aspiration regulator suction pump (Craft Duo-vac suction unit, Rocket Medical, England). The maximum aspiration pressure was set at 150 mmHg. When the needle tip entered the gestational sac, the pump was activated to aspirate. Methotrexate, 50 mg, was injected into the sac immediately after the embryo was removed by aspiration. Ten days later, ultrasound showed an empty sac about 1.5 cm in diameter. The hCG level decreased to 7981 miu/mL. Mild vaginal bleeding persisted intermittently for about eight weeks. Two months after aspiration, the hCG level was less than 5 miu/mL, and the empty sac had completely disappeared.

The predictability of serum anti-Müllerian level in IVF/ICSI outcomes for patients of advanced reproductive age

BackgroundThe role of serum anti-Müllerian hormone (AMH) as predictor of in-vitro fertilization outcomes has been much debated. The aim of the present study is to investigate the practicability of combining serum AMH level with biological age as a simple screening method for counseling IVF candidates of advanced reproductive age with potential poor outcomes prior to treatment initiation.MethodsA total of 1,538 reference patients and 116 infertile patients aged greater than or equal to 40 years enrolled in IVF/ICSI cycles were recruited in this retrospective analysis. A reference chart of the age-related distribution of serum AMH level for Asian population was first created. IVF/ICSI patients aged greater than or equal to 40 years were then divided into three groups according to the low, middle and high tertiles the serum AMH tertiles derived from the reference population of matching age. The cycle outcomes were analyzed and compared among each individual group.ResultsFor reference subjects aged greater than or equal to 40 years, the serum AMH of the low, middle and high tertiles were equal or lesser than 0.48, 0.49-1.22 and equal or greater than 1.23 ng/mL respectively. IVF/ICSI patients aged greater than or equal to 40 years with AMH levels in the low tertile had the highest cycle cancellation rate (47.6%) with zero clinical pregnancy. The nadir AMH level that has achieved live birth was 0.56 ng/mL, which was equivalent to the 36.4th percentile of AMH level from the age-matched reference group. The optimum cut-off levels of AMH for the prediction of nonpregnancy and cycle cancellation were 1.05 and 0.68 ng/mL, respectively.ConclusionsTwo criteria: (1) age greater than or equal to 40 years and (2) serum AMH level in the lowest tertile (equal or lesser than 33.3rd percentile) of the matching age group, may be used as markers of futility for counseling IVF/ICSI candidates.

The Effects of Brief Gamete Co-incubation in Human In Vitro Fertilization

AbstractPurpose: To investigate whether very short exposure ofmature oocytes to sperm in vitro may affect the fertilizationrates, embryo cleavage rates, and embryo quality betweensibling oocytes in the same patient. Methods: Sibling oocytes of the same patient from 23 oocytecollection cycles were randomly allocated to the study group,with a 1-hr or 3-hr sperm—oocyte incubation, or the controlgroup with the standard overnight gamete co-incubation.The fertilization rates, cleavage rates, and subsequentembryo quality were evaluated. Results: Our results showed no statistically significant differencesin fertilization rates, embryo cleavage rates, andquality of the embryos between the study group and thecontrol group. Conclusions: Since the present study showed that long exposureof the oocyte to sperm has no advantage over shortexposure, we prefer shortening the oocyte—sperm incubationperiod for reducing the negative effect induced bynonphysiologically high concentrations of spermatozoa.

A successful pregnancy with in vitro fertilization and embryo transfer in an infertile woman with Kartagener's syndrome : A case report

Kartageners syndrome (KS), a subgroup of the immotile-dyskinetic cilia syndrome, is a rare congenital disorder in the axoneme of the cilia characterized by the classic triad of recurrent rhinosinusitis, bronchiectasis, and situs inversus (1). The prevalence of this syndrome has been estimated at 1 in 40,000 (2). Up to the present time, it is generally considered that males with KS are almost all infertile (3,4), but the situation in female patients is not so clear. Some women with this syndrome are infertile (5-7), whereas some have successfully conceived (8-10). Although pregnancy is not impossible in women with KS, they are at high risk for sterility. Afzelius et al. reported only three successful pregnancies in 12 women with KS who tried to conceive (11). Recently, Halber and co-workers reported initial work with in vitro fertilization (IVF) and embryo transfer (ET) for a woman with infertility due to dyskinetic oviductal cilia caused by KS (7). Unfortunately, their patient did not conceive from that single IVF-ET attempt. Our study provides the first report of a successful pregnancy with IVF-ET in an infertile woman with KS. In addition, we are also the first to report an ectopic pregnancy in this syndrome.