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Routine Monitoring of Liver, Renal, and Hematologic Tests After Single- or Double-Dose Methotrexate Treatment for Ectopic Pregnancies After InÂ Vitro Fertilization. - Journal of minimally invasive gynecology
To investigate the trends in liver function tests (LFTs), renal function tests (RFTs), and complete blood count (CBC) between day 1 and day 7 after single- or double-dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies.Single center, retrospective chart review (Canadian Task Force classification II-3).University-affiliated center.All patients with a sonographically confirmed ectopic pregnancy after fresh inÂ vitro fertilization-embryo transfer cycles between January 2004 and June 2013 treated with MTX were included.Single- or double-dose MTX treatment.LFTs, specifically alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, and total bilirubin levels, were measured on day of MTX administration (baseline) and 7Â days later (day 7). Similar measurements of RFTs (blood urea nitrogen [BUN] and creatinine) and CBC (white blood cell [WBC] and platelets) were also performed. The change in LFTs, RFTs, and CBC (Î”) between baseline and day 7 was calculated for both single- and double-dose MTX protocols. Furthermore, the change in LFTs, RFTs, and CBC (Î” baseline vs day 7) for single- and double-dose MTX protocols were compared. Complete data was available for 107 patients: 89 (83.2%) and 18 (16.8%) patients received single- and double-dose MTX treatment, respectively. For either single- or double-dose treatment, no significant difference was found between baseline and day 7 ALT, AST, albumin, total bilirubin, BUN, creatinine, WBC, or platelet levels after MTX treatment. A comparison of post-treatment changes in LFTs, RFTs, and CBC (Î” baseline vs day 7) also showed no difference between single- and double-dose protocols.Our study suggests that repeating LFTs, RFTs, or CBC on day 7 after single- or double-dose MTX treatment for sonographically confirmed ectopic pregnancies may not be necessary in patients with normal baseline testing on dayÂ 1.Copyright Â© 2015 AAGL. Published by Elsevier Inc. All rights reserved.
Reproductive and oncologic outcomes after progestin therapy for endometrial complex atypical hyperplasia or carcinoma. - American journal of obstetrics and gynecology
This study evaluated fertility and oncological outcomes in women with complex atypical hyperplasia (CAH) or nonmyoinvasive grade 1 endometrioid endometrial carcinoma (EM) who desired fertility-sparing therapy.The retrospective cohort study included women younger than 45 years with CAH or EM who desired fertility-sparing treatment at our institution. Only patients for whom both oncological treatment and pregnancy outcomes were available were included. Statistical analyses were performed using a Fisher exact test, Pearson Ï‡(2) test, and Spearman rank correlation test, as appropriate.Seventy-five patients were identified, and 23 (13 CAH, 10 EM) met the inclusion criteria. All 23 patients had at least 1 prior pregnancy. Treatment was split between oral progesterone only (38.5% CAH, 40% EM), levonorgestrel intrauterine device only (30.8% CAH, 20% EM), and both (30.8% CAH, 40% EM). After a median follow-up of 13 months (range, 3-74 months), 9 patients (46.2% CAH, 30% EM, P = .39) had persistent/progressive disease. Eight patients (30.8% CAH, 40% EM, P = .69) ultimately had a hysterectomy, and 3 of these (13.0%) were found to have persistent/progressive disease. Median time from diagnosis to hysterectomy was 13 months (range, 4-56 months). Fourteen of the 23 patients utilized assisted reproductive techniques (60.9%); 12 underwent IVF and 2 chose a gestation carrier. Seven clinical intrauterine pregnancies (30.4%) resulting in 6 live births (26.1%) were found in the entire cohort.Fertility-sparing treatment for CAH and grade 1 endometrial cancer is feasible with progestin therapy and leads to clinically meaningful rates of pregnancy in young women who desire fertility.Copyright Â© 2014 Mosby, Inc. All rights reserved.
Unsuccessful planned conservative resection of placental site trophoblastic tumor. - Obstetrics and gynecology
Placental site trophoblastic tumor is a rare subtype of gestational trophoblastic neoplasia affecting women of reproductive age. The preferred method of treatment is surgical resection.A 33-year-old woman, gravida 3 para 1111, was incidentally diagnosed with placental site trophoblastic tumor during an evaluation for infertility. As a result of persistent pathologic evidence of disease, she underwent a hysterectomy. The site of disease on pathologic review of the hysterectomy specimen was widely discordant from the preoperative imaging and hysteroscopic evaluations.Wedge resection of the uterus has been suggested as an acceptable alternative to hysterectomy in women with placental site trophoblastic tumor who wish to preserve future fertility. However, this case demonstrated that preoperative imaging may not correlate with the tumor site, making wedge resection treatment ineffective.
Can inÂ vitro fertilization cycles be salvaged by repeat administration ofÂ intramuscular human chorionic gonadotropin the day after failed injection? - Fertility and sterility
To investigate the incidence of negative serum hCG level after initial IM trigger injection and whether such cycles can be salvaged through repeat administration of IM hCG.Retrospective cohort study.Academic medical center.All patients undergoing IVF at the Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, from January 1, 2005 to November 1,Â 2011.Repeat hCG administration in cases of failed initial trigger.Fertilization, implantation, clinical pregnancy, and live birth rates were analyzed in the index population compared with a control population matched for age, year of cycle start, diagnosis, stimulation protocol, number of prior IVF attempts, oocyte yield, and number of embryos transferred.The incidence of failed initial IM hCG injection was low, occurring in only 0.25% of the 17,298 fresh IVF cycles at our center during the study period. Of the 41 patients undergoing retrieval who received a second IM injection of hCG approximately 24 hours after the first, the live birth rate was 39.02%. Compared with matched controls, there were no statistical differences in oocyte maturity, fertilization, implantation, clinical pregnancy, or live birth rates.Although the incidence of failed hCG injection is rare, this study reveals that cycles characterized by incorrect initial administration or failed absorption of hCG can be salvaged by early detection and repeat injection. Assisted reproductive technology (ART) programs may benefit their patients through the assessment of either urine pregnancy tests or measurement of quantitative serum Î²-hCG levels before retrieval, thereby preventing empty follicle syndrome.Copyright Â© 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
Withholding gonadotropins until human chorionic gonadotropin administration. - Seminars in reproductive medicine
Withholding gonadotropins in women who exhibit high estradiol responses before follicles reach full maturation is called "coasting." Coasting, or suspending gonadotropin administration, can be an effective strategy for decreasing the risk of ovarian hyperstimulation syndrome (OHSS) while reducing cancelation rates. In in vitro fertilization cycles, mechanistically it is believed that withholding gonadotropins starves smaller follicles, induces apoptosis, and decreases the potential for these follicles to elaborate vascular endothelial growth factor, a known mediator of OHSS. It is generally accepted that coasting should be initiated when the estradiol (Eâ‚‚) level is >3000 pg/mL in the setting of immature follicles. The human chorionic gonadotropin (hCG) trigger should be administered when the Eâ‚‚ level subsequently drops to a "safe" level. Cycle cancellation should be considered if, after 3 to 4 days of coasting, the Eâ‚‚ level remains excessively elevated. Oocyte retrieval may also be cancelled if the Eâ‚‚ level on the day after hCG trigger drops precipitously. In gonadotropin-releasing hormone agonist (GnRHa)-based protocols, one can consider withholding GnRHa administration if the Eâ‚‚ level continues to increase after a few days of coasting. Current data seem to show that the coasting period is short and/or is less likely to be required in GnRH-antagonist protocols as compared with GnRHa-based protocols. Large randomized control trials are still needed to establish the relative efficacy of coasting versus embryo cryopreservation in the context of OHSS prevention.Â© Thieme Medical Publishers.
Stimulation of the young poor responder: comparison of the luteal estradiol/gonadotropin-releasing hormone antagonist priming protocol versus oral contraceptive microdose leuprolide. - Fertility and sterility
To evaluate in vitro fertilization (IVF) cycle outcomes in young poor responders treated with a luteal estradiol/gonadotropin-releasing hormone antagonist (E(2)/ANT) protocol versus an oral contraceptive pill microdose leuprolide protocol (OCP-MDL).Retrospective cohort.Academic practice.Poor responders: 186 women, aged <35 years undergoing IVF with either E(2)/ANT or OCP-MDL protocols.None.Clinical pregnancies, oocytes retrieved, cancellation rate.Patients in the E(2)/ANT group had a greater gonadotropin requirement (71.9 Â± 22.2 vs. 57.6 Â± 25.7) and lower E(2) level (1,178.6 Â± 668 vs. 1,627 Â± 889), yet achieved similar numbers of oocytes retrieved and fertilized, and a greater number of embryos transferred (2.3 Â± 0.9 vs. 2.0 Â± 1.1) with a better mean grade (2.14 Â± .06 vs. 2.7 Â± 1.8) compared with the OCP/MDL group. The E2/ANT group exhibited a trend toward improved implantation rates (30.5% vs. 21.1%) and ongoing pregnancy rates per started cycle: 44 out of 117 (37%) versus 17 out of 69 (25%).Poor responders aged <35 years may be treated with the aggressive E(2)/ANT protocol to improve cycle outcomes. Both protocols remain viable options for this group. Adequately powered, randomized clinical comparison appears justified.Copyright Â© 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.
Immunohistochemical expression of endometrial L-selectin ligand is higher in donor egg recipients with embryonic implantation. - Fertility and sterility
To correlate L-selectin ligand (LSL) expression in human endometrium with embryonic implantation.Retrospective cohort analysis.University-based fertility center.Donor egg recipients (DERs) who underwent programmed hormonal replacement for ET with prior mock cycle luteal phase endometrial biopsy.Immunohistochemical expression of LSL using MECA-79 antibody was examined. Slides were scored with a new scoring system, the IHC-Level (range 0-4) as follows: strength of staining-absent (0), weak (1), or strong (2); plus distribution of staining-absent (0), <50% of tissue (1), and >50% (2). Cellular apex and cytoplasm were scored independently in both the endometrial glandular and surface epithelium.Endometrial LSL expression in pregnant versus nonpregnant patients.MECA-79 IHC-Level of the apex of surface epithelium was significantly higher for pregnant versus nonpregnant DERs (3.8 vs. 3.4). When controlling for embryo morphology, there continues to be a significant difference in apex score on surface epithelium (3.8 vs. 3.3, respectively). The new scoring system results correlated with an established scoring system, the HSCORE.We demonstrate significantly higher expression of LSL at the apex of human endometrial surface epithelium obtained from DERs with embryonic implantation. Furthermore, we present the IHC-Level, a method of evaluating immunohistochemistry that may be applied to other markers of endometrial receptivity.
Safety and efficacy of infertility treatment after conservative management of borderline ovarian tumors: a preliminary report. - Fertility and sterility
To evaluate the safety and efficacy of infertility treatment in a group of patients after conservative management of borderline ovarian tumors.Retrospective study.University IVF unit.Five patients with previous conservative treatment of borderline ovarian tumor.Seventeen IVF cycles.Recurrence, IVF outcome.At the time of diagnosis, the mean age of the patients was 32.2 +/- 6.9 years. The mean time elapsed between the initial diagnosis of a borderline tumor and the performance of IVF was 42.2 months. After IVF, the mean number of oocytes retrieved was 7.9 +/- 4.0 with a mean fertilization rate of 57.1% and a mean number of 3.1 +/- 1.4 day 3 embryos transferred. Six pregnancies were achieved in three of the five patients with a pregnancy rate per retrieval of 37.5% and per transfer of 42.9%. The mean follow-up time that elapsed since the first IVF cycle was 39.2 months (range 9-78 months). One patient had three recurrences 13, 27, and 43 months after her first IVF cycle, all of which remained histologically serous borderline tumor. All patients were without evidence of disease at the time of last follow-up.At a mean follow-up time of 39.2 months, our results suggest that IVF may be considered for patients with conservatively treated borderline tumors. Furthermore, overall IVF success rates were very satisfactory, suggesting no perceptible negative impact of prior borderline ovarian neoplasia on pregnancy rates after IVF.
Preimplantation genetic diagnosis of human congenital heart malformation and Holt-Oram syndrome. - American journal of medical genetics. Part A
Holt-Oram syndrome (HOS) is a multiple malformation syndrome associated with congenital heart malformation (CHM) and caused by mutations in the TBX5 transcription factor. Effective prenatal genetic diagnosis of HOS is limited by factors that modify clinical manifestations and confound prediction of an individual's phenotype. Although preimplantation genetic diagnosis (PGD) has been applied to complex disorders with some cardiovascular manifestations, its utility in Mendelian CHM has not been previously demonstrated. We tested whether PGD and in vitro fertilization (IVF) technology, including oocyte donation, can identify fertilized eggs affected by HOS for potential embryo selection. Five donor oocytes were fertilized in vitro with sperm from a HOS patient heterozygous for a Glu69ter-TBX5 mutation and then underwent embryo biopsy and genotyping. One carried the Glu69ter-TBX5 mutation; all others had wildtype genotypes. Two wildtype blastocysts were transferred to the mother, and the resulting singleton pregnancy was successfully delivered. Mutational analysis of fetal amniocytes and postpartum umbilical cord blood confirmed PGD. Fetal ultrasonography as well as postpartum electrocardiography and echocardiography also validated accurate prediction of normal skeletal and cardiac phenotypes. We conclude that PGD is an effective reproductive strategy for HOS patients. As more genetic etiologies for CHM are identified, application of PGD as adjunctive therapy to IVF will be increasingly available to prevent transmission of such diseases from affected parents to their children. Clinical application of PGD must balance the benefits of avoiding disease transmission with the medical risks and financial burdens of IVF.Copyright 2003 Wiley-Liss, Inc.
Female patients with lymphoma demonstrate diminished ovarian reserve even before initiation of chemotherapy when compared with healthy controls and patients with other malignancies. - Journal of assisted reproduction and genetics
The purpose of this study is to investigate if female patients with lymphoma demonstrate diminished ovarian reserve prior to initiation of the lymphoma treatment.Sixty-four patients with newly diagnosed lymphoma undergoing controlled ovarian hyperstimulation for fertility preservation were compared with 365 healthy controls undergoing elective oocyte cryopreservation (controlled ovarian hyperstimulation (COH)) and 128 patients with other types of malignancy prompting fertility preservation. The data of all lymphoma patients, all elective, and all the patients with other types of malignancy who met the inclusion criteria and underwent COH for fertility preservation during the study period were retrospectively analyzed. Primary outcomes included serum anti-MÃ¼llerian hormone (AMH) levels (ng/mL) and antral follicle count (AFC).Patients in the lymphoma group demonstrated significantly lower AMH levels and AFC and had less oocytes harvested and cryopreserved when compared to healthy controls as well as patients with other malignancies.Patients with lymphoma demonstrate diminished ovarian reserve when compared with healthy controls and patients with other malignancies. This should be taken into consideration when deciding on the dose for COH.
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