The role of HCG increment in the 48h prior to methotrexate treatment as a predictor for treatment success.

OBJECTIVE: To evaluate the role HCG change in the 48h prior to methotrexate treatment as a predictor for treatment success. STUDY DESIGN: Medical records of all women who were diagnosed with ectopic pregnancy between January 2001 and June 2013 were reviewed. Four hundred and nine patients received methotrexate due to ectopic pregnancy. The "single dose" methotrexate protocol with 50mg/m2 was administered to patients with progressing ectopic pregnancy. HCG levels in days 1, 4 and 7 were used to evaluate methotrexate treatment success. The percentage of HCG change in the 48h prior to methotrexate treatment was compared between patients who were successfully treated and those who failed treatment with methotrexate. RESULTS: Single dose methotrexate was successful in 309 patients (75.4%, success group). The medians of HCG change in the 48h prior to methotrexate administration were significantly higher in the "failure group" (21% vs. 4%, p<0.01). In a logistic regression analysis, the of HCG percent increment prior to methotrexate administration was shown to be an independent predictor for treatment outcome. Receiver operator characteristic curve for HCG percent change was 0.751, at a cutoff value of HCG increment <12% the positive predictive value for treatment success reached 86%. CONCLUSIONS: Percentage of HCG increment in the 48h prior to methotrexate administration is an independent predictor for methotrexate treatment success. HCG increment <12% prior to methotrexate treatment is a good predictor for treatment success.

Second-dose methotrexate in ectopic pregnancies: the role of beta human chorionic gonadotropin.

OBJECTIVE: To evaluate the role of ß-hCG levels on days 1, 4, and 7 after methotrexate as predictors for second-dose requirement and success. DESIGN: Retrospective cohort study. SETTING: Tertiary university-affiliated hospital. PATIENT(S): A total of 1,703 patients were admitted because of ectopic pregnancy. Four hundred nine received methotrexate, of whom 73 women required a second dose. INTERVENTION(S): The "single-dose" methotrexate protocol with 50 mg/m(2) was administered to patients with progressing ectopic pregnancy. Surgical intervention was performed in cases of methotrexate second-dose treatment failure. MAIN OUTCOME MEASURE(S): Methotrexate second-dose requirement and success according to ß-hCG levels on days 1, 4 and 7. RESULT(S): Second-dose methotrexate was successful in 58 patients (79.4%, success group), whereas 15 patients (20.6%) failed treatment and required surgical intervention (failure group). The medians of ß-hCG levels on days 1, 4, and 7 were significantly higher in the "failure group" (1,601 vs. 2,844, 2,164 vs. 3,225, and 1,915 vs. 3,745 mIU/mL, respectively). Logistic regression analysis demonstrated that day-1 ß-hCG levels were the only significant independent variable for second-dose treatment outcome. The receiver operating characteristic curve for ß-hCG levels on day 1 was 0.727, and at a cutoff value of 2,234 mIU/mL the sensitivity and specificity reached the optimum for treatment success (77.5% and 73.3%, respectively). CONCLUSION(S): Day-1 ß-hCG levels were the only predictors for methotrexate second-dose requirement and treatment success. The cutoff value of ß-hCG on day 1 with the optimal treatment results was found to be 2,234 mIU/mL.

Methotrexate success rates in progressing ectopic pregnancies: a reappraisal.

OBJECTIVE: The purpose of this study was to determine the success rates of methotrexate in progressing ectopic pregnancies and to correlate them with beta-human chorionic gonadotropin (ß-hCG) levels. STUDY DESIGN: This retrospective cohort study that was carried out in a tertiary university-affiliated medical center included women who had been diagnosed with ectopic pregnancies between January 2001 and June 2013. Daily ß-hCG follow-up examinations were performed to determine the progression of the ectopic pregnancy. Women with hemodynamically stable progressing ectopic pregnancies received methotrexate (50 mg/m(2) of body surface). We measured the success and failure rates for methotrexate treatment in correlation to ß-hCG level. RESULTS: One thousand eighty-three women were candidates for "watchful waiting" (ß-hCG follow up). Spontaneous resolution and decline of ß-hCG levels occurred in 674 patients (39.5%); 409 women (24.0%) had stable or increasing ß-hCG levels and were treated with methotrexate. In 356 women (87.0%), the treatment was successful; 53 women (13.0%) required laparoscopic salpingectomy. Compared with prompt administration of methotrexate, our protocol resulted in lower overall success rates for all levels of ß-hCG in women with progressing ectopic pregnancies: 75% in women with ß-hCG levels of 2500-3500 mIU/mL, and 65% in women with ß-hCG levels >4500 mIU/mL. A mathematic model was found describing the failure rates for methotrexate in correlation with ß-hCG levels. CONCLUSION: The success rates for methotrexate treatment in progressing ectopic pregnancies after daily follow-up evaluation of ß-hCG levels are lower than previously reported. This reflects redundant administration of methotrexate in cases in which the ectopic pregnancy eventually will resolve spontaneously.

The value of diagnostic hysteroscopy before operative hysteroscopy for suspected abnormal intrauterine findings.

STUDY OBJECTIVE: To evaluate the accuracy of diagnostic office hysteroscopy in the detection of abnormal uterine findings in symptomatic and asymptomatic patients and compare it with the accuracy of operative hysteroscopy. DESIGN: A retrospective analysis of all women after operative hysteroscopy between 2010 and 2012 in our institution (Canadian Task Force classification II-2). SETTING: The department of gynecology in a tertiary referral medical center. PATIENTS: One hundred thirty-two patients with a mean age of 48 years after diagnostic office hysteroscopy and subsequent operative hysteroscopy. INTERVENTIONS: Operative hysteroscopy. MEASUREMENTS AND MAIN RESULTS: We collected demographic and clinical data from patients' charts. The indications as well as findings of the previous diagnostic modality (transvaginal ultrasound [TVUS] and diagnostic hysteroscopy) were gathered and compared with the final tissue diagnosis obtained via operative hysteroscopy. Positive predictive values in diagnostic hysteroscopy were calculated for common pathological intrauterine findings. Forty-eight patients (37%) were menopausal, and 84 (63%) were premenopausal. The indications for hysteroscopy were abnormal uterine bleeding in 46% of patients and suspected uterine finding in 44%. A TVUS preceded the diagnostic hysteroscopy in 105 women (80%). Older female age, menopausal status, and abnormal intrauterine findings larger than 15 mm were associated with significantly greater true-positive rates on diagnostic hysteroscopy (i.e., the suspected findings on diagnostic hysteroscopy were verified by final pathology). Uterine bleeding during the interval between procedures was marginally significant and associated with greater false-positive results. Bleeding as opposed to routine evaluation of uterine cavity, interval between procedures, location of intrauterine finding, and hormone replacement therapy were not associated with greater true-positive values. CONCLUSION: Although diagnostic hysteroscopy is superior to TVUS in the assessment of polyps, it contributes little to TVUS when myomas and endometrial hyperplasia are suspected. Therefore, it should not be used routinely as an interface between TVUS and operative hysteroscopy when such findings such are suspected. Furthermore, in premenopausal patients with abnormal uterine bleeding between diagnostic and operative procedures and when small (<15 mm) polyps are suspected, it might be worthwhile to repeat a diagnostic procedure before operative hysteroscopy.

Deep endometriosis inflicting the bladder: long-term outcomes of surgical management.

OBJECTIVE: To assess the efficacy and safety of laparoscopic treatment of bladder endometriosis, especially in cases of full thickness endometriotic nodules. DESIGN: Retrospective review of medical records. SETTING: Tertiary medical center and a referral center for endometriosis. POPULATION: Sixty-nine patients with bladder endometriosis that underwent surgery between January 2005 and December 2011. METHODS: The records of all patients with bladder endometriosis were reviewed and the pre-, intra- and postoperative information of patients who underwent surgery was collected. MAIN OUTCOME MEASURES: Efficacy, safety and long-term outcome of laparoscopic treatment of bladder endometriosis. RESULTS: The mean age of 69 patients with bladder endometriosis was 31.3 ± 4.6 years. Preoperative urinary symptoms (such as frequency, urgency, dysuria and others) were present in 28 (40.0%) patients. Laparoscopy was performed in all patients. Deep detrusor involvement was found in 45 (65.2%) patients. Of these, 21 patients underwent partial cystectomy due to a full thickness lesion. Deep nodule resection without bladder invasion was performed in 24 (34.8%) patients and bladder nodule coagulation and ablation in the remaining 24 (34.8%) patients with superficial involvement. No intraoperative complications were noted. Postoperative follow-up results were available for all patients. After a median (range) follow-up period of 60 (4-92) months, 92.7% of the patients were asymptomatic or reported improvement in symptoms. CONCLUSIONS: After a long-term follow-up surgical management of bladder endometriosis is strongly recommended. During surgery, careful inspection and full excision of bladder lesions should be performed. Laparoscopic excision is a safe and efficacies approach.

Effects of salpingectomy on ovarian response in controlled ovarian hyperstimulation for in vitro fertilization: a reappraisal.

To evaluate the effects of salpingectomy on ovarian response in controlled ovarian hyperstimulation (COH), 36 women who underwent controlled ovarian stimulation cycles for IVF before and after salpingectomy were studied. The overall number of dominant follicles and the number of oocytes aspirated before and after salpingectomy were comparable (7.2 ± 3.8 vs. 7.3 ± 3.7 and 10.2 ± 6.6 vs. 10.3 ± 7.4, respectively) as well as maximal E(2) levels, daily doses of gonadotropins, and the number of dominant follicles before and after surgery on the operated side, demonstrating that salpingectomy does not influence ovarian response in COH.

Virtual azoospermia and cryptozoospermia--fresh/frozen testicular or ejaculate sperm for better IVF outcome?

Men diagnosed as having azoospermia occasionally have a few mature sperm cells in other ejaculates. Other men may have constant, yet very low quality and quantity of sperm cells in their ejaculates, resulting in poor intracytoplasmic sperm injection (ICSI) outcome. It has not been conclusively established which source of sperm cells is preferable for ICSI when both ejaculate and testicular (fresh or frozen) sperm cells are available. It is also unclear whether there is any advantage of fresh over frozen sperm if testicular sperm is to be used. We used ejaculate, testicular (fresh or frozen) sperm cells, or both for ICSI in 13 couples. Five of these couples initially underwent ICSI by testicular sperm extraction, because the males had total azoospermia, and in later cycles with ejaculate sperm cells. Ejaculate sperm cells were initially used for ICSI in the other 8 patients, and later with testicular sperm cells. The fertilization rate was significantly higher when fresh or frozen-thawed testicular sperm cells were used than when ejaculated sperm cells were used. Likewise, the quality of the embryos from testicular (fresh and frozen) sperm was higher than from ejaculated sperm (65.3% vs 53.2%, respectively, P < .05). The use of fresh testicular sperm yielded better implantation rates than both frozen testicular sperm and ejaculate. Therefore, fresh testicular sperm should be considered first for ICSI in patients with virtual azoospermia or cryptozoospermia because of their superior fertility.

The effect of CGG repeat number on ovarian response among fragile X premutation carriers undergoing preimplantation genetic diagnosis.

OBJECTIVE: To assess ovarian response among carriers of FMR1 premutation who undergo preimplantation genetic diagnosis (PGD). DESIGN: Retrospective study. SETTING: Academic IVF unit. PATIENT(S): Of 18 carriers of FMR1 premutation referred to PGD, eight had <100 CGG repeats and ten had >or=100 CGG repeats. INTERVENTION(S): Controlled ovarian stimulation (COH) and PGD. MAIN OUTCOME MEASURE(S): Correlation between the number of CGG repeats and the level of E2 at day of hCG administration, number of retrieved oocytes, number of two-pronuclear (2PN) zygotes, and dose of recombinant FSH. RESULT(S): There was a positive correlation between CGG repeats and the level of E2 at day of hCG administration, number of retrieved oocytes, and number of 2PN zygotes. There was a negative correlation between number of CGG repeats and the total dose of gonadotropins. The E2 level and the number of retrieved oocytes and 2PN zygotes were significantly higher and the dose of gonadotropins significantly lower for premutation patients with >or=100 CGG repeats compared with <100 CGG repeats. CONCLUSION(S): There is a positive correlation between E2 level, retrieved oocytes, 2PN zygotes, and number of CGG repeats. Premutation carriers with <100 CGG repeats suffer from impaired ovarian response and decreased fertilization rate.

Coiling characteristics of umbilical cords in breech vs. vertex presentation.

OBJECTIVE: To compare selected umbilical cord parameters, especially cord coiling, between breech and vertex presentations. METHODS: We prospectively collected umbilical cords from uncomplicated breech and vertex obtained during elective term cesarean deliveries. We compared various cord parameters between the two groups as well as data regarding obstetric history and pregnancy outcome. RESULTS: We evaluated 55 umbilical cords from breech and 55 from vertex deliveries. Umbilical cord length (56.93 cm vs. 63.95 cm, P=0.05), number of coils (5.1+/-0.4 vs. 11.7+/-0.6, P<0.0001) and umbilical cord index (UCI) (0.09 coils/cm vs. 0.18 coils/cm, P<0.0001) were all significantly lower for breech presentations and remained significant following multivariate analysis. CONCLUSION: We document significant differences in umbilical coiling and the UCI between breech and vertex presentation. The precise reason for these differences is still unclear.

Compositional and oxidative analysis in the saliva and serum of predialysis chronic kidney disease patients and end-stage renal failure patients on peritoneal dialysis.

Chronic renal failure (CRF) is often treated with peritoneal dialysis, although increased oxidative stress has been reported in such patients. The purpose of the current study was to analyze and compare oxidative stress and other compositional parameters in the saliva, serum and peritoneal dialytic fluid (PDF) of patients with chronic kidney disease (CKD), including predialysis CKD patients and end-stage renal disease (ESRD) patients treated with peritoneal dialysis. Twenty-three consenting patients participated in the current study. Saliva and serum samples collected from both groups and PDF from the dialysis patients were all examined for uric acid (UA), total antioxidant status, total protein and total albumin. The antioxidant enzyme peroxidase was examined both in saliva and serum, while the antioxidant enzyme superoxide dismutase (SOD) was examined solely in saliva. Various electrolytes were examined. Discrepancies were found between saliva and serum antioxidant status following peritoneal dialysis in ESRD patients. Oxidative stress was enhanced in the saliva but reduced in the serum. Significant changes in both oxidative-related and non-related parameters were demonstrated in saliva, serum and PDF. Salivary lactate dehydrogenase was substantially lower in the dialysis patients (by 92%, P = 0.02), as was the salivary UA concentration (by 22%, P = 0.05) and serum UA concentration (by 20%, P = 0.03). In contrast, salivary peroxidase and SOD were higher by 15% and 35%, respectively (P = 0.01), in these patients. We suggest monitoring salivary UA for assessing the baseline oral oxidative status of CRF and dialyzed patients.