Human chorionic gonadotropin-administered natural cycle versus spontaneous ovulatory cycle in patients undergoing two pronuclear zygote frozen-thawed embryo transfer

OBJECTIVE: To compare human chorionic gonadotropin (HCG)-administered natural cycle with spontaneous ovulatory cycle in patients undergoing frozen-thawed embryo transfer (FTET) in natural cycles. METHODS: In this retrospective cohort study, we analyzed the clinical outcome of a total of 166 consecutive FTET cycles that were performed in either natural cycle controlled by HCG for ovulation triggering (HCG group, n=110) or natural cycle with spontaneous ovulation (control group, n=56) in 166 infertile patients between January 2009 and November 2013. RESULTS: There were no differences in patients' characteristics between the 2 groups. The numbers of oocytes retrieved, mature oocytes, fertilized oocytes, grade I or II embryos and frozen embryos in the previous in vitro fertilization (IVF) cycle in which embryos were frozen were comparable between the HCG and control groups. Significant differences were not also observed between the 2 groups in clinical pregnancy rate (CPR), embryo implantation rate, miscarriage rate, live birth rate and multiple CPR. However, the number of hospital visits for follicular monitoring was significantly fewer in the HCG group than in the control group (P < 0.001). CONCLUSION: Our results demonstrated that HCG administration for ovulation triggering in natural cycle reduces the number of hospital visits for follicular monitoring without any detrimental effect on FTET outcome when compared with spontaneous ovulatory cycles in infertile patients undergoing FTET in natural ovulatory cycles.

Prediction of pregnancy complication occurrence using fetal cardiac output assessments made by ultrasonography at 20 to 24 weeks of gestation

OBJECTIVE: To evaluate the importance of assessment of fetal cardiac output (CO) for the prediction of complications of pregnancy. METHODS: We evaluated 65 fetuses and all of them had a fetal cardiac scan at 20 to 24 weeks of pregnancy. To measure CO, diameters (d) of the left right ventricle outflow tract were measured just above the valves. Each left CO (LCO) and right CO (RCO) was derived using the following equation: CO = velocity time integral ×π× d²/4 × heart rate. Pregnancy complications included gestational hypertensive disorders, fetal growth restriction (FGR) and preterm birth (PTB) caused from preterm labor or preterm premature rupture of membrane (PPROM). RESULTS: There were 23 cases with one more pregnancy complication (FGR, 9; gestational hypertensive disorders, 8; PTB caused from PTB or PPROM, 12). The LCO was lower in complication group than in normal group (88±53 vs. 117±48 mL/min, P=0.028). The RCO to the LCO ratio (RCO/LCO) was higher in complication group (2.43±1.69 vs. 1.48±0.81, P=0.001). Regression analysis demonstrated that RCO/LCO was a significant predictor of pregnancy complication; Odds ratio was 7.76 (95% CI, 1.15 to 52.21; P=0.029). The area under the receiver-operating characteristic curve for prediction of pregnancy complications from LCO was 0.71. The diagnostic cut-off value of LCO was 80 mL/min. The area under the receiver-operating characteristic curve from RCO/LCO was 0.68 and cut-off value was 1.41. CONCLUSION: This study demonstrated that pregnancy complications can be suspected based on fetal CO assessments at a GA of 20 to 24 weeks.

A live birth after spontaneous complete chorioamniotic membrane separation associated with uterine scar

Spontaneous complete chorioamniotic membrane separation (CMS) without invasive fetal procedure is extremely rare and associated with adverse perinatal outcomes. A woman with complete CMS which was detected at the 21 weeks' gestation. She did not take any fetal invasive procedures before the diagnosis. At 27 weeks' gestation, an emergency Caesarean section was performed because of fetal distress. The defect of the uterine muscle was detected on the fundus. The baby has grown well without any morbidity. This is the first reported case of complete CMS relative to uterine scar. And we suggest that the pregnancy can be maintained successfully if there is no fetal abnormality when complete CMS is detected on ultrasound.

Subclinical hypothyroidism diagnosed by thyrotropin-releasing hormone stimulation test in infertile women with basal thyroid-stimulating hormone levels of 2.5 to 5.0 mIU/L

OBJECTIVE: To investigate the prevalence of subclinical hypothyroidism (SH) diagnosed by thyrotropin-releasing hormone (TRH) stimulating test in infertile women with basal thyroid-stimulating hormone (TSH) levels of 2.5 to 5.0 mIU/L. METHODS: This study was performed in 39 infertile women with ovulatory disorders (group 1) and 27 infertile women with male infertility only (group 2, controls) who had basal serum TSH levels of 2.5 to 5.0 mIU/L and a TRH stimulating test. Serum TSH levels were measured before TRH injection (TSH0) and also measured at 20 minutes (TSH1) and 40 minutes (TSH2) following intravenous injection of 400 microg TRH. Exaggerated TSH response above 30 mIU/L following TRH injection was diagnosed as SH. Group 1 was composed of poor responders (subgroup A), patients with polycystic ovary syndrome (subgroup B) and patients with WHO group II anovulation except poor responder or polycystic ovary syndrome (subgroup C). RESULTS: The prevalence of SH was significantly higher in group 1 of 46.2% (18/39) compared with 7.4% (2/27) in group 2 (P=0.001). TSH0, TSH1, and TSH2 levels were significantly higher in group 1 than the corresponding values in group 2 (P<0.001, P<0.001, P<0.001). In group 1, TSH1 and TSH2 levels were significantly lower in subgroup C compared with those in subgroup A and B (P=0.008, P=0.006, respectively). CONCLUSION: TRH stimulation test had better be performed in infertile women with ovulatory disorders who have TSH levels between 2.5 and 5.0 mIU/L for early detection and appropriate treatment of SH.

Luteal estradiol supplementation in gonadotropin-releasing hormone antagonist cycles for infertile patients in vitro fertilization / 대한생식의학회지

OBJECTIVE: To evaluate the effect of the addition of estradiol to luteal progesterone supplementation in GnRH antagonist cycles for infertile patients undergoing IVF/ICSI. METHODS: One hundred and ten infertile patients, aged 28 to 39 years, were recruited for this prospective randomized study. They were randomly assigned to receive vaginal progesterone gel (Crinone) along with 4 mg estradiol valerate (group 1, n=55) or only Crinone (group 2, n=55) for luteal support. A GnRH antagonist multiple dose protocol using recombinant human FSH was used for controlled ovarian stimulation (COS) in all of the subjects. The COS results and pregnancy outcomes of the two groups were compared. RESULTS: Group 1 and 2 were comparable with respect to the patient characteristics. The COS and IVF results were also comparable between the two groups. There were no differences in the clinical pregnancy rate (PR) and multiple PR between the two groups. However, the embryo implantation rate were significantly higher in group 1 than that in group 2 (22.2% vs. 13.3%, p=0.035). The incidence of luteal vaginal bleeding (LVB) was significantly lower in group 1 (7.4% vs. 27.8%, p=0.010). CONCLUSION: The addition of estradiol to luteal progesterone supplementation in GnRH antagonist cycles reduces the incidence of LVB and increases the embryo implantation rate in infertile patients undergoing IVF/ICSI.

Effectiveness of GnRH antagonist multiple dose protocol applied during early and late follicular phase compared with GnRH agonist long protocol in non-obese and obese patients with polycystic ovary syndrome undergoing IVF/ICSI / 대한생식의학회지

OBJECTIVE: To evaluate the effectiveness of GnRH antagonist multiple dose protocol applied during early and late follicular phase (MDP-EL) in comparison with standard GnRH agonist luteal long protocol (LP) in each non-obese and obese polycystic ovary syndrome (PCOS) women undergoing IVF. METHODS: Two hundred eleven infertile women with PCOS were recruited and randomized to undergo either GnRH antagonist MDP-EL (antagonist group) or standard GnRH agonist luteal LP (agonist group). IVF cycle outcomes were compared between the two groups. RESULTS: Total dose and days of recombinant human follicle stimulating hormone (rhFSH) administered were significantly fewer in the antagonist group than in the agonist group. Incidence of severe ovarian hyperstimulation syndrome was significantly lower in the antagonist group. However, IVF and pregnancy outcomes were similar in the two groups. When all subjects were divided into non-obese and obese subgroups, in non-obese PCOS subgroup, IVF and pregnancy outcomes were comparable in the antagonist and agonist groups but total dose and days of rhFSH were also significantly fewer in the antagonist group. Similar findings were also observed in obese PCOS subgroup. CONCLUSION: GnRH antagonist MDP-EL is at least as effective as GnRH agonist LP and may be a more patient-friendly alternative in controlled ovarian stimulation for PCOS patients undergoing IVF, independent of body mass index.

Comparison of follitropin beta administered by a pen device with follitropin beta administered by a conventional syringe in patients undergoing IVF-ET / 대한생식의학회지

OBJECTIVE: To compare the effectiveness and convenience of a pen device for the self-administration of follitropin beta with a conventional syringe delivering follitropin beta solution in patients undergoing IVF-ET. METHODS: GnRH agonist long protocol was used for controlled ovarian stimulation (COS) in all subjects. A total of 100 patients were randomized into the pen device group or the conventional syringe group on the first day of COS. Local tolerance reactions were assessed within 5 minutes, at 1 hour and at 3 hours after each injection. On the day of hCG injection, patients were asked to rate their overall pain and convenience experienced with self-injection on a visual anlaogue scale (VAS). RESULTS: There were no differences in patients' characteristics between the two groups. The duration of COS was significantly shorter in the pen device group than in the conventional syringe group. Patients included in the pen device group needed a significantly smaller amount of follitropin beta. However, no differences between the two groups were found in IVF results and pregnancy outcome. The incidence of local pain within 5 minutes, at 1 hour and at 3 hours after the injection was significantly lower in the pen device group. VAS scores indicated that injections using the pen device were significantly less painful and more convenient. CONCLUSION: The pen device for self-administration of follitropin beta is less painful, safer and more convenient for the patients, and can be more effective because of the shorter duration and smaller dose of follitropin beta when compared with the conventional syringe.

Comparison of follitropin beta administered by a pen device with follitropin beta administered by a conventional syringe in patients undergoing IVF-ET / 대한생식의학회지

OBJECTIVE: To compare the effectiveness and convenience of a pen device for the self-administration of follitropin beta with a conventional syringe delivering follitropin beta solution in patients undergoing IVF-ET. METHODS: GnRH agonist long protocol was used for controlled ovarian stimulation (COS) in all subjects. A total of 100 patients were randomized into the pen device group or the conventional syringe group on the first day of COS. Local tolerance reactions were assessed within 5 minutes, at 1 hour and at 3 hours after each injection. On the day of hCG injection, patients were asked to rate their overall pain and convenience experienced with self-injection on a visual anlaogue scale (VAS). RESULTS: There were no differences in patients' characteristics between the two groups. The duration of COS was significantly shorter in the pen device group than in the conventional syringe group. Patients included in the pen device group needed a significantly smaller amount of follitropin beta. However, no differences between the two groups were found in IVF results and pregnancy outcome. The incidence of local pain within 5 minutes, at 1 hour and at 3 hours after the injection was significantly lower in the pen device group. VAS scores indicated that injections using the pen device were significantly less painful and more convenient. CONCLUSION: The pen device for self-administration of follitropin beta is less painful, safer and more convenient for the patients, and can be more effective because of the shorter duration and smaller dose of follitropin beta when compared with the conventional syringe.

Pioglitazone treatment decreases follicular fluid levels of tumor necrosis factor-alpha and interleukin-6 in patients with polycystic ovary syndrome / 대한생식의학회지

OBJECTIVE: To investigate the effects of pioglitazone on controlled ovarian stimulation (COS), IVF outcomes, and follicular fluid (FF) cytokine concentrations in patients with polycystic ovary syndrome (PCOS). METHODS: Eighty-six infertile patients with PCOS resistant to clomiphene citrate were randomized to receive pioglitazone (30 mg/day) or placebo on the starting day of oral contraceptive (OC) pretreatment, followed by an IVF protocol using a GnRH antagonist. Pioglitazone or placebo was administered once daily from the starting day of OC to the day of hCG injection. RESULTS: Total dose and days of recombinant follicle-stimulating hormone administered, and the numbers of retrieved and mature oocytes, were significantly lower in the pioglitazone group than in the control group. FF tumor necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6) concentrations at oocyte retrieval were also significantly lower in the pioglitazone group. The clinical pregnancy rate was higher and the incidence of severe ovarian hyperstimulation syndrome was lower in the pioglitazone group, but the differences were not statistically significant. CONCLUSION: Pioglitazone reduces FF TNF-alpha and IL-6 levels, and may improve ovarian response to COS in patients with PCOS.

GnRH antagonist multiple dose protocol with oral contraceptive pill pretreatment in poor responders undergoing IVF/ICSI / 대한생식의학회지

OBJECTIVE: To investigate the effectiveness of GnRH antagonist multiple-dose protocol (MDP) with oral contraceptive pill (OCP) pretreatment in poor responders undergoing IVF/ICSI, compared with GnRH antagonist MDP without OCP pretreatment and GnRH agonist low-dose long protocol (LP). METHODS: A total of 120 poor responders were randomized into three groups according to controlled ovarian stimulation (COS) options; GnRH antagonist MDP after OCP pretreatment (group 1), GnRH antagonist MDP without OCP pretreatment (group 2) or GnRH agonist luteal low-dose LP without OCP pretreatment (group 3). Patients allocated in group 1 were pretreated with OCP for 21days in the cycle preceding COS, and ovarian stimulation using recombinant human FSH (rhFSH) was started 5 days after discontinuation of OCP. RESULTS: There were no differences in patients' characteristics among three groups. Total dose and days of rhFSH used for COS were significantly higher in group 3 than in group 1 or 2. The numbers of mature oocytes, fertilized oocytes and grade I, II embryos were significantly lower in group 2 than in group 1 or 3. There were no significant differences in the clinical pregnancy rate and implantation rate among three groups. CONCLUSION: GnRH antagonist MDP with OCP pretreatment is at least as effective as GnRH agonist low-dose LP in poor responders and can benefit the poor responders by reducing the amount and duration of FSH required for follicular maturation.

Placental Mesenchymal Dysplasia Associated with a Fetal Unilateral Multicystic Dysplastic Kidney: A Case Report / 대한주산의학회잡지

Placental mesenchymal dysplasia (PMD) is a rare placental disorder that may coexist with a normal fetus but is frequently associated with fetal growth restriction, fetal demise, prematurity, and Beckwith-Wiedemann syndrome, as well as with various fetal anatomical and vascular anomalies. In this case, ultrasonography performed at 14 weeks of gestation revealed multiple, variable sized cysts in the placenta along with a morphologically normal fetus. Serial sonographic examinations found that the fetus became small for gestational age and had a dysplastic right kidney. After delivery at 33 weeks of gestation, histopathologic examination of the placenta showed enlarged, hydropic stem villi with cavity formation and absence of trophoblastic proliferation and pseudoinclusions, all of which were consistent with PMD. Neonatal abdominal ultrasonography showed multiple cysts in the right kidney consistent with a multicystic dysplastic condition. This appears to be the first case of PMD associated with fetal multicystic dysplastic kidney.

The clinicopathologic features of six cases of primary malignant cervical lymphoma / 대한산부인과학회지

OBJECTIVE: To provide clinical information for the best diagnosis and treatment of primary malignant cervical lymphoma based on the information obtained from these cases. METHODS: Between 1989 and 2006, six women with primary malignant cervical lymphoma were diagnosed and treated at our institution. Data were obtained from their medical records and were retrospectively analyzed. RESULTS: The mean patient age at the time of diagnosis was 63 (range 19-74). The chief complaint was vaginal bleeding in five women and the voiding difficulty for one woman. five of six patient had the cervical lesions (erosion and tumoral mass), while the other was non specific cervical findings. The Papanicolaou test was performed on three women, one of whom was HSIL. All six patients were confirmed with cervical lymphoma through the pathologic diagnosis. Surgical treatment (radical hysterectomy with bilateral salpingo- oophorectomy, pelvic lymph node dissection, and para-aortic lymph node dissection) was performed in one case, simple hysterectomy with complementary chemotherapy in two, and chemotherapy in one. Two patients refused treatment. Among four patients treated, one experienced recurrence in an ovary and the others have remained in remission. CONCLUSION: Primary malignant cervical lymphoma is a rare malignancy. Physicians can miss early detection of this disease because of its 'silent' symptoms and very low incidence. The accumulated data regarding this tumor can make it easy to detect at an early stage, thereby allowing it to be successfully treated. Further studies should be conducted to obtain further information regarding the cervical lymphoma.

A case of primary peritoneal origin malignant mixed mullerian tumor / 대한산부인과학회지

Malignant mixed mullerian tumor (MMMT) is rare and has pathologically carcinoma and sarcoma components. Among them, primary peritoneal MMMTs are extremely rare, and their proper treatment and prognosis are not well-known. We experienced a case of primary peritoneal origin MMMT, so we report it with a brief review of the literatures.