Two Cases of Primary Ovarian Insufficiency Accompanied by High Serum Anti-Müllerian Hormone Levels and Preservation of Ovarian Follicles

Primary ovarian insufficiency (POI) is defined as the presence of amenorrhea for ≥ 4 months accompanied by evidence of two serum follicle-stimulating hormone levels in the menopausal range in women aged < 40 years. Anti-Müllerian hormone (AMH) has been recognized as the most reliable marker of ovarian reserve status, and its serum level is very low or undetectable in women with POI.Here we report two cases of patients who were diagnosed with POI despite high serum AMH levels and preservation of ovarian follicles, as revealed by ultrasound. In addition, we have presented a review of the current literature regarding this condition.

Efficacy of hyaluronan-rich transfer medium on implantation and pregnancy rates in fresh and frozen-thawed blastocyst transfers in Korean women with previous implantation failure

OBJECTIVE: To evaluate the effect of hyaluronan-rich transfer medium on pregnancy and implantation rates in fresh and frozen-thawed embryo transfers in Korean women with previous implantation failure. METHODS: This retrospective study included 283 blastocyst transfers in patients with previous embryo transfer failure at a private fertility clinic. In the study group (n=88), blastocyst transfers were performed using an hyaluronan-rich transfer medium prior to transfer, whereas blastocyst transfers without any treatment served as controls (n=195). According to the type of transfer (fresh elective or frozen-thawed), all the blastocyst transfers were divided into two study and two control groups. RESULTS: The patient's mean age, serum anti-Müllerian hormone level, causes of infertility, embryo quality, and the number of transferred embryos were comparable between the study and control groups. There were no significant differences in clinical pregnancy rate (45.5% vs. 43.1%), implantation rate (28.9% vs. 28.8%), and clinical abortion rate (10.0% vs. 8.3%) between the two groups, and these findings were not changed after subgroup analysis according to the type of transfer. CONCLUSION: The use of hyaluronan-rich transfer medium in the blastocyst transfer does not appear to have any significant effect on the implantation and pregnancy rates in patients with previous implantation failure.

Expression of CD44 in endometrial stromal cells from women with and without endometriosis and its effect on the adherence to peritoneal mesothelial cells

OBJECTIVE: This study was performed to compare the expression of CD44 in endometrial stromal cells (ESCs) of women with and without endometriosis and to evaluate the role of CD44 in the adherence of ESCs to peritoneal mesothelial cells (PMCs). METHODS: A PMC adherence assay was performed to evaluate the adherence of ESCs to PMCs in women with and without endometriosis. The expression of CD44 mRNA was measured by reverse transcription-polymerase chain reaction. CD44 protein was evaluated by Western blot analysis. RESULTS: There were no significant differences in the expression of CD44 mRNA and protein in ESCs or in the binding of ESCs to PMCs between patients with endometriosis and controls. Although the expression of CD44 protein was decreased in both women with endometriosis and controls after anti-CD44 antibody treatment, there was no effect on binding of ESCs to PMCs. Treatment of ESCs with peritoneal fluid from endometriosis patients resulted in a significant increase in binding of ESCs to PMCs compared to untreated ESCs in the endometriosis group. CONCLUSION: This study demonstrates that the expression of CD44 protein in ESCs from women with endometriosis might not be directly associated with adherence to PMCs.

Mortality Associated with Hormone Replacement Therapy in Postmenopausal Women / 대한폐경학회지

There was controversy about decrease in mortality as the eventual result of hormone replacement therapy (HRT). The reduction of mortality was known in large observational-cohort studies in women with HRT compared with non-HRT after correction of confounding factors. The second analysis of Women's Health Initiative (WHI) results revealed that the 30% decrease in mortality was observed in HRT users. These findings resemble with the results of past observational studies. The meta-analysis including the second analysis of WHI results showed that HRT use in young menopausal women decrease the mortality. Although there was a chaos about the risk and benefit of HRT since the first announcement of WHI study in 2002, HRT in young menopausal women could decrease the morbidity and mortality related to coronary heart disease and stroke.

The infertility treatment related with polycystic ovary syndrome / 대한산부인과학회지

The treatment of infertile women with polycystic ovary syndrome (PCOS) has not yet been established. Before any intervention is initiated, lifestyle modification with diet and exercise leading to weight loss should be emphasized in overweight women. The recommended first-line treatment for ovulation induction remains clomiphene citrate. If clomiphene citrate use fails to result in ovulation or pregnancy, the recommended second-line intervention is exogenous gonadotropins. The use of exogenous gonadotropins is related to an increased risk for multiple pregnancies, and, therefore, intense ovarian response monitoring is required. Laparoscopic ovarian surgery is an alternative to gonadotropin therapy because this surgery is as effective as gonadotropin in pregnancy rate or live birth rate. However, the surgery may require additional ovulation induction drug and should be performed by well-trained surgeon, its use solely to induce ovulation is unwarranted. Recommended third-line treatment is in vitro fertilization (IVF). IVF reduces the risk of multiple pregnancies by using single-embryo transfer in women with PCOS. The use of metformin alone as first-line infertility therapy or in combination with clomiphene is surrounded by controversies. Aromatase inhibitors appear to be as effective as clomiphene citrate for induction of ovulation, but the drug is currently not approved for treatment of infertility. Further studies should demonstrate the efficacy and long term safety.

A case of successful treatment of stroke with intracardiac thrombi in a patient with severe ovarian hyperstimulation syndrome / 대한산부인과학회지

Thromboembolism is a rare complication of ovarian hyperstimulation syndrom (OHSS). According to the numerous reports, it most commonly occurs in upper extremities, head, and neck vein. It is also well known that acute cerebral infarction, once occurred, is mainly caused by the occlusion of large arteries, especially middle cerebral artery (MCA) in most cases. Administration of heparin has been considered as the best treatment option, but many studies have been reporting successful treatment results from administrating thrombolytics in patients with cerebral infarction. Although administration of thrombolytics is invasive and has some potential side effects including bleeding or hematoma, it still has been used for treating patients with cerebral infarction. We report a case of patient with intracardiac thrombi and manifested symptoms of acute cerebral infarction originally caused by OHSS followed by the occlusion of MCA. We administered thrombolytics within one and half hours of showing left hemiparesis caused by the occlusion of right MCA, and identified reperfusion of MCA. There was no evidence of complications associated with the administration of thrombolytics on CT scan, which was taken 24 hours later. Thrombi in IVC, right atrium, and right ventricle were found on chest CT with pleural effusion, but soon were disappeared after administrating heparin anticoagulation. We report this case to show that thrombolytics and anticoagulation can be safely used to treat a patient with cerebral infarction and thrombi caused by OHSS without any side effects or complications.

Clinical trial comparing recombinant human chorionic gonadotropin (hCG) to urinary hCG for induction of final follicular maturation in IVF-ET / 대한산부인과학회지

OBJECT: Human chorionic gonadotropin (hCG) is used to induce final follicular maturation in women undergoing controlled ovarian hyperstimulation (COH). Urinary preparations are associated with a number of disadvantages including an uncontrolled source, batch-to-batch variability and lack of purity. We performed this study to compare the efficacy of recombinant hCG and urinary hCG for induction of final follicular maturation in women undergoing IVF-ET. METHODS: Prospective trial was performed on a total of 84 IVF cycles carried out in 84 infertile women with tubal and peritoneal factor. Patients were randomized 1:1 to 250 microgram of recombinant hCG subcutaneous injection or 10,000 IU of urinary hCG intramuscular injection after completing recombinant human follicle stimulating hormone (FSH) stimulation. Oocyte pickup was scheduled 36 hours after hCG administration and embryos were transferred 3 days after oocyte pickup. We measured the efficacy points including the number of retrieved and fertilized oocytes, quality of oocytes and embryos, and clinical pregnancy rate. RESULTS: Serum progesterone and hCG level on post-hCG day 5 were significantly higher in the recombinant hCG group (p<0.01, p<0.05). There were no significant differences in outcome including the number of retrieved oocytes, quality of oocytes and embryos, clinical pregnancy rate between the two preparations. The incidence of injection-site reactions such as pain, itching, and bruising were significantly lower in the recombinant hCG group (p<0.01, p<0.01 and p<0.05). CONCLUSIONS: For triggering ovulation, recombinant hCG seems to have significant advantages compared with urinary hCG in terms of luteal progesterone and local tolerance.

Analysis of Preterm Birth Rate based on Birth Certificate Data: from 1995 to 2003 / 대한산부인과학회지

OBJECTIVE: This study was performed to evaluate changes in the preterm birth rate and risk factors of preterm birth in Korea. METHODS: A total number of 5,433,746 birth cases from the birth certificate data from 1995 to 2003 obtained from the National Statistical Office of Korea was reviewed and analyzed. We evaluated the annual preterm birth rate for 9 years, seasonal and regional variations, multiple birth rate, the preterm birth rate for women aged 35 years or older. The logistic regression analysis was used to examine the relationship between preterm birth and risk factors including maternal and paternal age, parity, infantile sex, season and region of birth. RESULTS: The preterm birth rate has increased from 4.25% in 1995 to 10.03% in 2003. Seasonal and regional variations were found. The preterm birth rate was 6.65% in spring, 7.75% in summer, 7.36 in autumn, and 7.38% in winter. The preterm birth rate was 5.06% in Jeollabuk-do, the lowest rate, and 9.17% in Ulsan, the highest rate in Korea. The multiple birth rate has increased from 1.32% in 1995 to 2.01% in 2003. The mean age at first birth was 26 years in 1995, 28 years in 2003, and first birth rate for women aged 35 years or older has increased from 2.4% in 1995 to 4.8% in 2003. The preterm birth rate for women aged 35 years or older also increased from 8.14% in 1995 to 14.74% in 2003. The risk for preterm birth was significantly higher in the women aged 35 years or older, compared with those under 35 years (OR: 1.572, p<0.001). The risk for preterm birth in father aged 40-70 years was higher than those under 30 years (OR: 1.316, p<0.001). In the order of birth, the risk was higher in second or more-born than first-born (OR: 1.122, p<0.001). The odds ratio of preterm birth by infantile sex was 0.84 in male (p<0.001). Risk was significantly higher in multiple birth than in singleton (OR: 20.078, p<0.001). CONCLUSION: Based on the birth certificate data from 1995 to 2003, the preterm birth rate in Korea has increased since 1995. Older maternal and paternal old age, multiparity, male infant, and multiple birth can be considered as risk factors for preterm birth.

Expression of Cathepsin B mRNA and Protein in Eutopic and Ectopic Endometrial Tissues of Patients with Endometriosis / 대한산부인과학회지

OBJECTIVE: This study was performed to investigate the expression of cathepsin B mRNA and Protein in eutopic and ectopic endometrial tissues of patients with endometriosis and in normal endometrial tissues, to compare the expression respectively and to clarify the correlation between the cathepsin B expression and endometriosis. METHODS: There were 34 women with endometriosis taken surgical treatment at Department of Obstetrics and Gynecology, Asan Medical Center, Seoul, Korea, from October 2004 to September 2005. All patients were pre-menopausal and not-pregnant, and had received neither hormones nor gonadotropin-releasing hormone agonist (GnRH-a) therapy for at least 6 months before surgical treatment. Control group consisted of 14 women who had undergone operative treatment for cervical intraepithelial neoplasia (CIN) or benign gynecologic conditions other than endometriosis during the same period at the same center. Eutopic endometrial tissues of both groups and ectopic endometrial tissue of study group were collected during the operations. We employed rea1 time quantitative reverse transcriptase-polymerase chain reaction (real time RT-PCR) to quantify cathepsin B mRNA of these tissues. And we performed western blot analysis to measure the quantity of cathepsin B protein. We compared the results using student's t-test and Mann-Whitney U-test. RESULTS: The expressions of cathepsin B mRNA and protein were significantly higher in both eutopic and ectopic endometrial tissues of women with endometriosis than in control endometrial tissues. The expression of cathepsin B mRNA of mid-secretory phase was less than proliferative phase, but there was no statistical significance. CONCLUSION: With marked expressions of cathepsin B in both eutopic and ectopic endometrial tissues of endometriosis, we might assume the association of cathepsin B with the development of endometriosis. In addition the eutopic endometrium in itself might play a role in the histogenesis of endometriosis.

Efficacy of transvaginal ultrasound-guided aspiration in benign pelvic cyst / 대한산부인과학회지

OBJECTIVE: We investigated the clinical efficacy and safety of transvaginal ultrasound-guided aspiration in treatment of benign pelvic cyst. METHODS: We analyzed medical records of the 343 women with pelvic cyst who underwent transvaginal ultrasound-guided aspiration between 1996 and 2004. We investigated the age, parity, tentative diagnosis, size of the cyst at short-, and long- term follow up, type of aspiration, character and cytology of the aspirated contents, and complication. RESULTS: Mean diameters were significantly reduced after transvaginal ultrasound-guided aspiration at short-, and long-term follow up in all types of cysts except lymphocele (p<0.05). However, at long-term follow up, the proportions of the cysts that were completely resolved or reduced in size greater than 50% after ultrasound-guided aspiration were only 37%, 24.8%, 28%, and 30% in simple cyst, endometrioma, pseudocyst, and lymphocele, respectively. No serious aspiration related complication was identified except two cases. One was ovarian abscess and the other was bladder puncture during aspiration. CONCLUSION: This study suggests that transvaginal ultrasound-guided aspiration of benign pelvic cyst is a simple and safe procedure, but the application of aspiration to simple cyst, pseudocyst, lymphocele should be prudent because of the limited therapeutic efficacy. But for patients with endometrioma who wish to be pregnant, transvaginal ultrasound-guided aspiration could be a good treatment option to preserve ovarian reserve function.

Successful pregnancy and birth in a patient with panhypopituitarism caused by craniopharyngioma / 대한산부인과학회지

Conceptions and uncomplicated pregnancies in patients with panhypopituitarism are rare especially after treatment of craniopharyngioma. We recently experienced a case of a patient with panhypopituitarism who became pregnant by gonadotropin therapy and gave birth to a healthy baby. A 33-year-old woman developed hypogonadotropic hypogonadism and diabetes insipidus because of craniopharyngioma which was surgically removed. Post-operative panhypopituitarism with diabetes insipidus was treated with adequate doses of L-thyroxin, prednisolone, desmopressin, medroxyprogesterone acetate (MPA), conjugated estrogen. To induce ovulation, human menopausal gonadotropin (hMG) and human chorionic gonadotropin (hCG) were administered, and a single intrauterine insemination (IUI) procedure was performed. The patient became pregnant and gave birth to a healthy baby. This case suggests that ovulation induction using gonadotropins and comprehensive hormone replacement therapy can result in the successful pregnancy in patients with panhypopituitarism after treatment of craniopharyngioma.