Outdoor air pollution and diminished ovarian reserve among infertile Korean women

BACKGROUND@#Mounting evidence implicates an association between ambient air pollution and impaired reproductive potential of human. Our study aimed to assess the association between air pollution and ovarian reserve in young, infertile women.@*METHODS@#Our study included 2276 Korean women who attended a single fertility center in 2016-2018. Women's exposure to air pollution was assessed using concentrations of particulate matter (PM@*RESULTS@#The mean age was 36.6 ± 4.2 years and AMH level was 3.3 ± 3.1 ng/mL in the study population. Average AMH ratio was 0.8 ± 0.7 and low AMH was observed in 10.3% of women (n=235). The average concentration of six air pollutants was not different between the normal ovarian reserve and low AMH groups for all averaging periods. In multivariable models, an interquartile range (IQR)-increase in 1 month-average PM@*CONCLUSIONS@#In a cohort of infertile Korean women, there was a suggestive evidence of the negative association between ambient PM concentration and ovarian reserve, highlighting the potential adverse impact of air pollution on women's fertility.

Therapeutic outcomes of methotrexate injection in unruptured interstitial pregnancy

OBJECTIVE: To examine the therapeutic outcomes of methotrexate (MTX) in the treatment of unruptured interstitial pregnancy. METHODS: We reviewed the medical records of patients who were diagnosed with interstitial pregnancy and received MTX as first-line treatment between January 2003 and July 2014 at CHA Gangnam Medical Center. The treatment success rates and subsequent pregnancy outcomes were examined. RESULTS: Ninety-seven patients were diagnosed with interstitial pregnancy between January 2003 and July 2014. Of them, 38 initially received MTX treatment. The diagnosis was made at a median of 6+3 weeks (5+0 to 11+3 weeks). Thirty patients received a systemic MTX injection, while the other 8 received a local MTX injection. Systemic treatment composed of an 8-day alternating MTX regimen, single-dose regimen, or high-dose regimen (100 mg/m2 + 200 mg/m2 intravenously over 12 hours). The local injection consisted of a direct MTX injection into the gestational sac with or without systemic MTX injection. Twenty-one patients (55.3%) were successfully treated with MTX. However, MTX therapy failed in 17 patients (44.7%), who required surgery. Mode of MTX treatment was the only predictive variable of MTX treatment success (P=0.039). Treatment success was seen in 7 of 8 patients (87.5%) in the local MTX group vs. 14 of 30 patients (46.7%) in the systemic MTX group. After treatment, 13 patients attempted a successive pregnancy; of them, 10 patients had a confirmed clinical pregnancy and healthy live birth. CONCLUSION: Combined MTX treatment including a local injection might be an initial approach to the treatment of interstitial pregnancy.

Application of serum anti-Müllerian hormone levels in selecting patients with polycystic ovary syndrome for in vitro maturation treatment / 대한생식의학회지

OBJECTIVE: The purpose of this study was to identify useful clinical factors for the identification of patients with polycystic ovary syndrome (PCOS) who would benefit from in vitro maturation (IVM) treatment without exhibiting compromised pregnancy outcomes. METHODS: A retrospective cohort study was performed of 186 consecutive patients with PCOS who underwent human chorionic gonadotropin-primed IVM treatment between March 2010 and March 2014. Only the first IVM cycle of each patient was included in this study. A retrospective case-control study was subsequently conducted to compare pregnancy outcomes between IVM and conventional in vitro fertilization (IVF) cycles. RESULTS: Through logistic regression analyses, we arrived at the novel finding that serum anti-Müllerian hormone (AMH) levels and the number of fertilized oocytes in IVM were independent predictive factors for live birth with unstandardized coefficients of 0.078 (95% confidence interval [CI], 1.005-1.164; p=0.037) and 0.113 (95% CI, 1.038-1.208; p=0.003), respectively. Furthermore, these two parameters were able to discriminate patients who experienced live births from non-pregnant IVM patients using cut-off levels of 8.5 ng/mL and five fertilized oocytes, respectively. A subsequent retrospective case-control study of patients with PCOS who had serum AMH levels ≥8.5 ng/mL showed that IVM had pregnancy outcomes comparable to conventional IVF, and that no cases of ovarian hyperstimulation syndrome were observed. CONCLUSION: Serum AMH levels are a useful factor for predicting pregnancy outcomes in PCOS patients before the beginning of an IVM cycle. IVM may be an alternative to conventional IVF for PCOS patients if the patients are properly selected according to predictive factors such as serum AMH levels.

Chronic endometritis and infertility / 대한생식의학회지

Chronic endometritis (CE) is a condition involving the breakdown of the peaceful co-existence between microorganisms and the host immune system in the endometrium. A majority of CE cases produce no noticeable signs or mild symptoms, and the prevalence rate of CE has been found to be approximately 10%. Gynecologists and pathologists often do not focus much clinical attention on CE due to the time-consuming microscopic examinations necessary to diagnose CE, its mild clinical manifestations, and the benign nature of the disease. However, the relationship between CE and infertility-related conditions such as repeated implantation failure and recurrent miscarriage has recently emerged as an area of inquiry. In this study, we reviewed the literature on the pathophysiology of CE and how it may be associated with infertility, as well as the literature regarding the diagnosis and treatment of CE. In addition, we discuss the value of hysteroscopic procedures in the diagnosis and treatment of CE.

Percutaneous Thrombin Injection with Balloon Occlusion for the Treatment of a Femoral Artery Pseudoaneurysm / 대한내과학회지

Femoral artery pseudoaneurysm (FAP) is an uncommon but potentially serious vascular complication that may develop after cardiac and peripheral angiographic procedures. Here we describe the case of a 75-year-old female who presented with a life-threatening bleeding episode due to an FAP 4 days after diagnostic coronary angiography, which was treated with a percutaneous thrombin injection and transient balloon occlusion of the femoral artery during thrombin injection. This case reminds us of the importance of close observation and proper evaluation for complications, even if the risk of bleeding complications is low. Furthermore, although ultrasound-guided compression and a percutaneous thrombin injection are the standard treatment for FAP, this case demonstrates that transient balloon dilation during the percutaneous injection of thrombin is an important treatment option in cases of a wide-necked pseudoaneurysm in which the risk of thrombin escape is high.

A Case of Ticagrelor Rescue Therapy in a Patient with Subacute Stent Thrombosis / 대한내과학회지

Stent thrombosis (ST) is a rare but catastrophic complication of a drug-eluting stent. Although dual antiplatelet therapy with aspirin and clopidogrel significantly reduces the occurrence of ST, it continues to occur and is occasionally associated with clopidogrel resistance. Here, we describe a 71-yr-old man with subacute stent thrombosis and clopidogrel resistance following drug-eluting stent implantation who underwent successful ticagrelor rescue therapy.

A Case of Ticagrelor Rescue Therapy in a Patient with Subacute Stent Thrombosis / 대한내과학회지

Stent thrombosis (ST) is a rare but catastrophic complication of a drug-eluting stent. Although dual antiplatelet therapy with aspirin and clopidogrel significantly reduces the occurrence of ST, it continues to occur and is occasionally associated with clopidogrel resistance. Here, we describe a 71-yr-old man with subacute stent thrombosis and clopidogrel resistance following drug-eluting stent implantation who underwent successful ticagrelor rescue therapy.

A Case of Deep Vein Thrombosis Following Ultrasound-Guided Compression of a Pseudoaneurysm / 대한내과학회지

Femoral artery pseudoaneurysm (FAP) is one of the most troublesome groin complications related to femoral arterial access during invasive cardiovascular procedures. Ultrasound-guided compression is the initial treatment for FAP. Here, we describe the case of a 65 year-old female who developed significant deep vein thrombosis (DVT) following ultrasound-guided compression of FAP after percutaneous coronary intervention. She was successfully treated with anti-coagulation medications. This case, along with a brief review of the literature, should remind physicians of the possible occurrence of delayed vascular complications, such as DVT, after ultrasound-guided compression of FAP.

A Case of Vertebral Osteomyelitis With Epidural Abscess Caused by Mycobacterium intracellulare in a Rheumatoid Arthritis Patient

Mycobacterium avium complex (MAC) is the most common pathogen in nontuberculous mycobacterial lung diseases, but vertebral osteomyelitis caused by MAC is rare. We experienced a case of vertebral osteomyelitis with epidural abscess in a rheumatoid arthritis patient who received immunosuppressive agents. Initial assessment was tuberculous vertebral osteomyelitis, and then treated with antituberculous drugs. Fifty-six days later, Mycobacterium intracellulare was identified from abscess culture and drugs were altered to clarithromycin, rifabutin, and ethambutol. After 3 months of M. intracellulare treatment, the radiological findings showed increases of epidural abscess. According to the suseptibility, the patient received intravenous amikacin for four weeks, and then, oral ciprofloxacin in addition to clarithromycin, rifabutin, and ethambutol. The patient is being treated with the medication for 13 months and currently showing slow improvements.

A Case of Adenocarcinoma of the Transverse Colon with Humoral Hypercalcemia of Malignancy

Hypercalcemia is a common electrolyte imbalance in patients with malignancy. Approximately 80% of hypercalcemia is associated with humoral hypercalcemia of malignancy (HHM), but occurs rarely in colorectal carcinomas. A 72-year-old man was admitted with abdominal pain and bowel habit change. Colonoscopy showed a malignant tumor in the transverse colon. Laboratory data showed an elevated serum calcium level (11.6 mg/dL) and elevated parathyroid hormone-related peptide level (12.2 pmol/L). Histology showed poorly differentiated adenocarcinoma. We infused intravenous normal saline, furosemide and pamidronate. The serum calcium level was subsequently normalized. However, the patient died from cancer progression 10 days later. With a review of the relevant literature, we report a case of adenocarcinoma of the transverse colon with HHM.

Effects of various combinations of cryoprotectants and cooling speed on the survival and further development of mouse oocytes after vitrification / 대한생식의학회지

OBJECTIVE: The objectives of this study were to analyze efficacy of immature and mature mouse oocytes after vitrification and warming by applying various combinations of cryoprotectants (CPAs) and/or super-rapid cooling using slush nitrogen (SN2). METHODS: Four-week old ICR female mice were superovulated for GV- and MII-stage oocytes. Experimental groups were divided into two groups. Ethylene glycol (EG) only group: pre-equilibrated with 1.5 M EG for 2.5 minutes and then equilibrated with 5.5 M EG and 1.0 M sucrose for 20 seconds. EG+dimethylsulfoxide (DMSO) group: pre-equilibrated with 1.3 M EG+1.1 M DMSO for 2.5 minutes and equilibrated with 2.7 M EG+2.1 M DMSO+0.5 M sucrose for 20 seconds. The oocytes were loaded onto grids and plunged into SN2 or liquid nitrogen (LN2). Stored oocytes were warmed by a five-step method, and then their survival, maturation, cleavage, and developmental rates were observed. RESULTS: The EG only and EG+DMSO groups showed no significant difference in survival of immature oocytes vitrified after warming. However, maturation and cleavage rates after conventional insemination were greater in the EG only group than in the EG+DMSO group. In mature oocytes, survival, cleavage, and blastocyst formation rates after warming showed no significant difference when EG only or EG+DMSO was applied. Furthermore, cleavage and blastocyst formation rates of MII oocytes vitrified using SN2 were increased in both the EG only and EG+DMSO groups. CONCLUSION: A combination of CPAs in oocyte cryopreservation could be formulated according to the oocyte stage. In addition, SN2 may improve the efficiency of vitrification by reducing cryoinjury.

Clinical manifestations and risk factors of severe ovarian hyperstimulation syndrome by IVF-ET / 대한산부인과학회지

OBJECTIVE: The aim of this study is to determine the incidence, clinical predictors, clinical manifestations of severe ovarian hyperstimulation syndrome in a large group. METHODS: A retrospective analysis of all IVF-ET cycles was performed from January 2005 to October 2007. We analysed incidence of severe OHSS and clinical manifestation. We assessed transvaginal number of follicles on hCG, serum estradiol, numbers of oocytes as the predictive factors comparing severe OHSS group and control group. Chi-square test and Student's t-test were used. Pleural effusion group was assessed identically. RESULTS: 6,292 IVF-ET cycles were undertaken in which 133 cycles of severe OHSS was developed (incidence: 2.11%). Patients age, transvaginal number of follicles on hCG, serum estradiol, numbers of oocytes were high in severe OHSS group and lately developed OHSS patients were all pregnant. 43.6% of severe OHSS were diagnosed polycystic ovarian syndrome. Pleural effusion was develop in 28 patients (incidence : 0.45%) and there were no predictive factor of pleural efusion. CONCLUSIONS: The incidence of severe OHSS was 2.11%. The protocol of controlled ovarian hyperstimulation did not affect the incidence of severe OHSS. Transvaginal number of follicles on hCG, serum estradiol, numbers of oocytes, PCOS, pregnancy were meaningful risk factors. There were no predicting factor for the pleural effusion of severe OHSS.

Risk factors for ectopic pregnancy after fresh non-donor in vitro fertilization and embryo transfer / 대한산부인과학회지

OBJECTIVE: To find risk factors for ectopic pregnancy among women who conceived after fresh non-donor in vitro fertilization and embryo transfer (IVF-ET). METHODS: A total of 2,326 cycles conceived after fresh non-donor IVF-ET between January 2002 and December 2005 were studied with regard to patient factors, and factors related to the ART procedures through review of their medical chart. Risk factors in ectopic pregnancy were assessed by using chi-square test and multivariate logistic regression analysis. RESULTS: Of 2,326 pregnancies of fresh non-donor IVF-ET cycles, 135 (5.8%) were ectopic pregnancies. Most of ectopic pregnancies were tubal type (79 cases, 58.5%) and combined type (40 cases, 29.6%). Most of ectopic pregnancies (87.4%) were treated by laparoscopic surgery. In comparison with clinical pregnancy group, estradiol level checked on human chorionic gonadotrophin (hCG) injection day for final follicular maturation and mean number of oocytes retrived were higher in ectopic group. respectively, (2,228.9 vs. 1,906.9 pg/ml, p=0.022; 13.8 vs. 11.6, p=0.001). In univariate analysis, the risk for ectopic pregnancy was increased among women with tubal factor infertility (odds ratio [OR] 1.7, 95% confidence interval [CI] 1.20-2.35) and, decreased among women with male factor infertility (OR 0.7, 95% CI 0.47-0.94) and use of intracytoplasmic sperm injection (ICSI) (OR 0.7, 95% CI 0.50-0.98). However, in multivariate logistic regression analysis, only tubal factor was an independent predictor for ectopic pregnancy. CONCLUSIONS: Tubal factor infertility is the main risk factor for ectopic pregnancy following fresh non-donor IVF-ET.

A case of abdominal pregnancy on abdominal scar following in vitro fertilization and embryo transfer in a patient with bilateral tubal obstruction / 대한산부인과학회지

Abdominal pregnancy is a rare event following in vitro fertilization and embryo transfer. In case of early abdominal pregnancy, it is difficult to diagnose and treat early because of nonspecific symptoms. The abdominal pregnancy in a woman with tubal obstruction is very exceptional and an abdominal pregnancy on abdominal scar have not been reported. We reported the first abdominal pregnancy on abdominal scar following in vitro fertilization and embryo transfer in a woman with unilateral salpingectomy and contralateral tubal obstruction.

Clinical evaluation of ultrasound-guided embryo transfer / 대한산부인과학회지

OBJECTIVE: Clinical evaluation of the efficacy of ultrasound-guided embryo transfer (ET) comparing with embryo transfer without ultrasound guidance (Non-US). METHODS: From January 2003 to April 2003, we examined the efficacy of ultrasound-guided embryo transfer (ET) on clinical outcome from in-vitro fertilization (IVF-ET) cycle. One hundred thirty patients were prospectively randomized into two groups: 69 patients had ultrasound-guided ET (US) and 61 patients had clinical touch embryo transfer without ultrasound guidance (Non-US). RESULTS: There were no statistically significant differences between the two groups with respect to age, cause of infertility, and the characteristics of the IVF cycle. The pregnany rate (42.0%: 40.9%, p=0.9043) and implantation rate (26.6%: 23.1%; p=0.5057) were similar in both groups. CONCLUSION: There was no significant improvement in pregnancy and implantation rates, following the use of ultrasound guidance during ET, but ultrasound assistance would suggest that decrease in cervical and uterine trauma, decrease in the total duration of ET time, and increase in the easy transfer rate can play a positive role in embryo transfer.

ACase of the Patau Syndrome Diagnosed in Second Trimester / 대한주산의학회잡지

Patau syndrome is trisomy 13, one of the most common autosomal aberration associated with multiple congenital anomalies. Because trisomy 13 is generally associated with severe congenital anomalies and postpartum poor prognosis, antenatal diagnosis through antenatal ultra-sonogram and triple screening marker is very important. We present one case of trisomy 13 with abnormal ultrasound finding, holoprosencephaly, microcephaly, cleft lip and palate. And confirmed chromosomally with pregnancy termination.

Clinical efficacy of GnRH antagonist multiple dose protocol and GnRH agonist long protocol in controlled ovarian hyperstimulation using rFSH in IVF-ET patients / 대한산부인과학회지

OBJECTIVE: To compare the efficacy of GnRH antagonist multi dose protocol in controlled ovarian hyperstimulation (COH) for IVF-ET or ICSI with GnRH agonist long protocol. METHODS: From January 2003 to December 2004, total of 583 cycles which underwent IVF-ET or ICSI using r-FSH were enrolled in this study. 447 cycles of the study group were performed in controlled ovarian hyperstimulation by using GnRH antagonist multi dose protocol and 136 cycles of the control group were performed by using GnRH long protocol. We compared patients characteristics, controlled ovarian hyperstimulation outcomes and IVF-ET outcomes between two groups. RESULTS: Patients characteristics and baseline hormone levels were not different between the two groups. The duration of stimulation was significantly shorter in study group comparing with control group (12.8+/-1.5 days vs 13.7+/-1.7 days, p<0.05). There were no differences between the two groups in the number of follicles, endometrial thickness and serum E2 level on hCG day. The pregnancy rate seemed to be lower in the study group (32.4% vs 35.4%), but the difference was not statistically significant. There were also no differences in number of oocytes retrieved, matured oocytes, fertilized oocytes and transferred embryos between two groups. CONCLUSION: GnRH antagonist multi dose protocol in COH might be a simple and effective method compared with GnRH agonist long protocol.

Simultaneous bilateral tubal pregnancy following in-vitro fertilization and embryo transfer / 대한산부인과학회지

A case of simultaneous bilateral tubal pregnancy following in-vitro fertilization and embryo transfer is presented. On the 22 days after ET, the patient complained of low abdominal pain and vaginal spotting for one day and was suspected of left tubal pregnancy by transvaginal ultrasonography. However, laparoscopy revealed the bilateral tubal pregnancy and laparoscopic bilateral salpingectomy was performed. This unusual type of ectopic pregnancy must be kept in mind when evaluating a patient suspected of a possible early abnormal gestation after assisted reproductive technologies. It is critical to perform a close inspection of the abdomen, pelvis, and contralateral tube during surgery.

Simple Total Laparoscopic Hysterectomy: A clinical Evaluation of 312 Cases / 대한산부인과학회잡지

OBJECTIVE: This study was conducted to evaluate the clinical efficacy of simple total laparoscopic hysterectomy in the aspect of operation indication, operation time, hospitalization day, blood loss, and postoperative complications. METHODS: A retrospective evaluation for 312 women who undergone simplified total laparoscopic hysterectomy from January, 2002 to June, 2003 was done. RESULTS: The mean age of patients was 45.2 years, mean parity was 2.2, and mean uterine weight was 272.3 gm. The most common surgical indication was uterine myoma in 136 cases (43.5%), followed by adenomyosis in 90 cases (28.8%), myoma combined with adenomyosis in 52 cases (16.6%), uterine prolapse in 15 cases (4.8%), and HSIL 19 cases (6%) respectively. The most common concomitant operation was salpingooophorectomy in 53 cases (16.9%), followed by adhesiolysis in 40 cases (12.8%), colporraphy in 14 cases (4.4%), electrocauterization (ovary) in 4 cases (1.3%), pelvic floor suspension in 4 cases (1.3%), and TVT in 1 case (0.3%). The mean operation time was 107 minutes, and the average hospital day was 5.2 days. The preoperative and postoperative hemoglobin difference was 1.2 gm/dL. The complications of STLH were ureteral injury in 2 cases, intestinal injury in 1 case, and stump bleeding in 1 case. CONCLUSION: The most important factors for successful STLH were sufficiently trained laparoscopic team and the degree of pelvic adhesion. The most potential advantages of STLH are shorter duration of operation time, hospitalization, and less postoperative complications and more cost effectiveness. Therefore, STLH can be a new alternative option for hysterectomy and may replace the other methods of hysterectomy such as abdominal, vaginal and laparoscopic assisted vaginal hysterectomy (LAVH).

A Case of Sirenomelia In One Fetus of Twin Pregnancy / 대한산부인과학회잡지

Sirenomelia is a lethal congenital malformation characterized by single or fused lower limbs associated with other severe genitourinary and lower gastrointestinal tract anomalies. Associated anomalies include malformation of vertebrae and pelvis, oligohydroamnios, renal agenesis, imperforate anus, internal and external genital anomaly and single umbilical artery. Recently, sirenomelia is diagnosed by ultrasound at first trimester or early second trimester. Termination of pregnancy is recommended as soon as diagnosis is made. We report a case of sirenomelia in a monoamniotic twin gestation detected at IUP at 12 weeks which was maintained till IUP at 37 weeks and delivered by cesarean section. On autopsy, typical finding of sirenomelia was noted, whereas the contralateral twin showed no abnormalities.