International Journal of Fertility and Womens Medicine最新文献

Ovarian hyperstimulation syndrome (OHSS) is a rare and potentially life-threatening complication during controlled ovarian stimulation. It can be associated with severe morbidity and may even be fatal. The etiology of the condition and predisposing factors are still not fully understood. Data concerning pathophysiology in patients with OHSS were searched using PubMed and other medical data bases. The incidence of severe OHSS, as calculated by World Health Organization (WHO), is 0.2-1% of all stimulation cycles in assisted reproduction. Considerations on OHSS classifications and forms of manifestations are discussed in detail. New insights concerning genetics and altered FSH receptor are given. OHSS may involve, according to its grade of severity, elevated or decreased levels of growth factors, cytokines, mediators, changes in hormones, renin-angiotensin and kinin-kallikrein system. There are massive electrolytic imbalances and changes in hemodynamic and fluid metabolism. Furthermore, liver and pulmonary dysfunction is observed as well as increased coagulation with subsequent thromboembolism. The influence of OHSS on the pregnancy rate and outcome of pregnancy is a matter of controversy. Patients with OHSS have high pregnancy rates with a tendency to an increased incidence of abortion.

Objectives and methods: In 100 anovulatory infertile women with polycystic ovary syndrome attending the infertility clinic of this institute, transvaginal ultrasound findings of ovaries were correlated with both clinical and hormonal parameters using Chi-square test.

Results: All women in the study had oligomenorrhea or amenorrhea, 70% had hirsutism and more than half were obese. On transvaginal ultrasound, ovarian volume was more than 10 cm3 in all, 90% had more than 10 follicles in each ovary, 75% had stromal thickness more than 1 cm and more than half had increased stromal echogenicity. Seventy percent had high testosterone levels and 60% were detected to have insulin resistance. Ovarian volume correlated positively with body mass index, waist/hip ratio and menstrual cycle irregularity (p < 0.05). The correlation between ovarian size, LH/FSH ratio and hyperinsulinemia was highly significant (p < 0.005), but was low for serum androgens and also hirsutism. Number of follicles per ovary correlated positively with body mass index, menstrual irregularity (p < 0.01), insulin resistance as well as androgens (p < 0.005). Positive predictive value of ovarian follicle number was 100% for insulin resistance as well as D4 androstenedione. Increased stromal thickness also showed 70% positive prediction for clinical parameters, 66% for insulin resistance and 82% for serum D4 androstenedione. Contrary to the other ultrasound parameters of polycystic ovary, stromal echogenicity did not significantly correlate with any of the clinical or hormonal parameters except serum testosterone.

Conclusion: Transvaginal ultrasonography of the ovaries confirms the clinical profile and also gives an insight to the hormonal milieu of the women with PCOS.

Purpose: The purpose of the present study is to compare intrauterine insemination (IUI) pregnancy rates (PR) as a function of diagnosis and ovulation protocol utilizing an extended semen transport time. This allowed clients to conveniently collect IUI specimens in the comfort and privacy of their home. A single IUI per treatment cycle was performed.

Basic procedures: Three-hundred-ten consecutive infertilty couples having unexplained, male factor, ovulatory dysfunction, endometriosis, tubal factor or combined diagnostic factors receiving a total of 584 cycles of IUI were included. Ovulation protocols included LH surge, clomiphene citrate (CC)-hCG, CC-gonadotropins(Gn)-hCG, Gn-hCG or leuprolide acetate (L)-Gn-hCG followed 36-42 hours by a single IUI. Pregnancy rates per cycle (fecundity) and per couple (fertility) as a function of diagnosis, ovulation protocol and cycle number were evaluated. In each cycle the couples processed the specimen by adding sperm washing medium at room temperature to the specimen 30 min following collection and allowed it to incubate for two hours prior to IUI during transport.

Main findings: Overall, fecundity was 11.8% (69/584) and fertility was 22.3% (69/310); respectively by diagnosis was: unexplained 22.6%, 38.8%; male factor 18.8%, 42.9%; ovulatory dysfunction 12.4, 22.6%; endometriosis 5.3%, 11.1%; tubal factor 7.6%,13.3%; and combined factors 9.7%, 20.0%. Unexplained vs endometriosis (P < 0.0001, P < 0.005), tubal factor (fecundity P < 0.008) and ovulatory dysfunction (fecundity P < 0.027) was statistically different. Male factor vs endometriosis (P < 0.011, P < 0.036) was significantly different. Ovulatory dysfunction vs endometriosis was significantly different (fecundity P < 0.027). Pregnancies by ovulation protocol: LH surge 4.5%,10.5%; CC-hCG 9.4%,14.9%; CC-Gn-hCG 13.7%, 23.7%; Gn-hCG 17.5%, 45.3%; L-Gn-hCG 3.5%, 6.7%. For Gn-hCG vs L-Gn-hCG (P < 0.009, P < 0.030) and LH surge (fecundity P < 0.033). CC-Gn-hCG vs CC-hCG (fertility P < 0.050) and L-Gn-hCG (P < 0.033, P < 0.034). Gn-hCG vs CC-hCG (fecundity P < 0.043).

Conclusions: We conclude that IUI is effective when utilizing an extended transport time allowing most couples to collect the specimen at home and is most effective when utilizing Gn-hCG therapy. Based on our analysis, endometriosis, tubal factor and combined diagnostic categories should proceed earlier to higher level assisted reproductive technologies.

The B-Lynch surgical technique for the management of massive postpartum hemorrhage (PPH) has been used successfully since 1989 in cases where bleeding was secondary to uterine atony with failed conservative management. It allows for conservation of the uterus for subsequent menstrual function and pregnancies. In this report, we present a follow up of a case with successful pregnancy ten years after PPH was managed with the B-Lynch uterine compression suture to demonstrate the long-term anatomical consequences of this operation. This case represents the longest follow up after the application of the B-Lynch suture (brace suture) technique for the control of massive PPH as an alternative to hysterectomy. Published data have confirmed that on the balance of probability, the B-Lynch surgical technique is safe, effective and free of short- and long-term complication.

Objectives: To assess intra- and interobserver agreement in cervical volume and flow indices measurements.

Method: We prospectively examined 126 patients by two seperate observers using transvaginal 3D gray-scale and power Doppler ultrasound. The two acquired volume datasets were analyzed using the VOCAL imaging program for assessing cervical volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI). Reproducibility of volume and vascularity measurement was assessed by calculating intraclass (intra-CC) and interclass (inter-CC) correlation coefficients (ICCs).

Results: Both intraobserver and interobserver cervical volume measurements were in perfect agreement with intra-CC values of 0.95, 0.96 for both examiners and with an inter-CC value of 0.95. Intraobserver agreement for VI, FI and VFI measurements were as good as the interobserver agreement for VI, and VFI measurements were adequate but less for FI measurements (inter-CC 0.67). Overall, volumetric data were more reliably acquirable than power Doppler measurements.

Conclusions: 3D ultrasound gray-scale and power Doppler measurement of cervical volume and vascularization have acceptable intra- and interobserver variations and thus may be used in clinical research of cervical physiology and pathophysiology during pregnancy.

Medical tourism, a term that also can be used to describe medical outsourcing, is characterized by travel away from one's home region to procure treatment in another. It may take one of two forms: obligatory or elective. The former occurs when necessary treatments are unavailable or illegal in the place of origin. The latter includes elective and medically indicated procedures that, although available at the place of origin, may be delivered more quickly or in a more cost-effective manner in another location. Reproductive outsourcing is a special form of medical tourism that has quickly become an important area of present-day medicine because the changes of the last four decades have left all but the most advanced fertility centers breathless as they try to adjust their treatment protocols in effective and ethical manners. Legal and policy limitations have created a global environment where, in a rising number of instances, individuals and couples must travel elsewhere to procure fertility procedures that are unavailable back home. With low cost airfares to and from America, a growing number of "medical cartographers" have set out to map which places are the "best" (in terms of cost, effectiveness and timeliness), for what procedures, and for whom. On the other hand, physicians, legal experts and policy makers have only begun to shape how government and health care agencies should formally guide or regulate medical tourism. In doing so, a number of factors may challenge the limits of ethics, policy and legality in this most important trend in modern medicine.

Objective: The purpose of this study was to examine the outcome of pregnancies in women suffering blunt abdominal trauma, which preceded birth.

Methods: A retrospective cohort study was performed comparing patients who did and did not suffer blunt abdominal trauma preceding birth. Deliveries occurred during the years 1988-2002 in a tertiary medical center. Data regarding abdominal trauma that led to birth was available from the perinatal database of the center. Stratified analysis, using a multiple logistic regression model, was performed to control for confounders.

Results: Fifty-four cases of blunt abdominal trauma leading to birth were identified out of 159,223 deliveries that occurred during the study period. Using a multivariate analysis, with backward elimination, placental abruption (OR = 10.0; 95% CI 3.9-25.5; P < 0.001) and preterm delivery (OR = 2.5; 95% CI 1.3-5.0; P = 0.008) were found to be significantly associated with blunt abdominal trauma. A higher rate of Cesarean deliveries was noted among women suffering abdominal trauma (24.1% vs. 12.2%, P = 0.019). No significant differences were found regarding the perinatal outcome between women who did and did not suffer abdominal trauma, as demonstrated by an Apgar score of less than seven at one (7.4% vs. 4.5%, P = 0.30) and five minutes (1.9% vs. 0.6%, P = 0.28) and by perinatal mortality rates (3.7% vs. 1.5%, P = 0.19).

Conclusion: Blunt abdominal trauma was significantly associated with placental abruption and preterm delivery. However, the perinatal outcome of these pregnancies was not significantly different from that of the general population.

Routine post partum complete blood count examination (CBC) is customary in many medical centers. The rationale behind drawing a routine CBC is to estimate blood loss during delivery and to identify patients who will need blood transfusions. The present study was aimed to determine the necessity of routine post-partum CBC following vaginal delivery. A retrospective cohort study was performed including all patients who received blood transfusions following vaginal delivery between January 2003 and November 2004. Data were collected from birth files. The indications for administration of blood transfusions were noted. Of 20,694 vaginal deliveries, 0.7% (n = 138) received blood transfusions. All patients had at least one obstetric risk factor of postpartum hemorrhage or symptomatic anemia. None received the blood transfusion based upon postpartum CBC hemoglobin level alone. Routine postpartum CBC is not warranted for the purpose of identifying the patient in need of blood transfusions. Postpartum CBC should be performed when indicated according to risk factors for excessive blood loss or patients' complaints.

Background: Fetal heart rate (FHR) monitoring is commonly used for fetal surveillance. Despite its widespread usage, there is still a disagreement about its value in predicting fetal distress.

Case: A 29-year-old woman in her first pregnancy was admitted for routine follow-up at 38 weeks gestation. The FHR tracing demonstrated severely reduced baseline variability. Due to non-reassuring FHR patterns accompanied by abnormal biophysical profile, the patient was scheduled for urgent Cesarean section. A newborn with congenital absence of the thyroid gland was delivered.

Conclusion: Severe reduced baseline variability might be an early sign for fetal hypothyroidism. Future research in this area may examine large populations of neonates with thyroid abnormalities in order to determine if abnormal FHR tracing can better predict congenital hypothyroidism.