Search

Surgery for massive abdominal tumors is both interesting and challenging. We present a case involving a multiple uterine myoma weighing 6.2 Kg which coincided with omental leiomyosarcoma. To our knowledge, this is the first report of this type of condition in the English literature. A 44-year-old nulliparous woman had suffered from abdominal pain for a long time. A huge abdominal mass was palpated on physical examination. Computed tomography scanning revealed a huge pelvic-abdominal mass with the possibility of small bowel loops invaded by the mass. A 6-cm omental mass was incidentally found during the subsequent hysterectomy procedure. Perforation of the urinary bladder occurred during the dissection of adhesion. Resection of the omental mass, wide wedge resection of the invaded small bowel, primary repair of the bladder, and hysterectomy were performed. The final pathologic diagnosis was uterine leiomyomata with omental leiomyosarcoma. The patient returned home on postoperative day 14 and was well at the 18-month follow-up examination. The challenge of these tumors lies in their proper diagnosis and surgical management. More case reports and follow-up studies are needed to confirm the efficacy of their management.

Retinal detachment is an unusual complication of hypertensive disorder in pregnancy. It has been reported in 1% to 2% of patients with severe preeclampsia and in 10% of patients with eclampsia. Choroidal ischemia may be the cause of retinal detachment. We know that mild arteriolar spasm involving the bulbar conjunctival vessels has been observed in the normal pregnancy, but in pregnancy-induced hypertension the vasospasm may be severe and result in choroidal ischemia. Most patients with retinal detachment in pregnancy-induced hypertension have had full spontaneous resolution within a few weeks, and they did not have any sequelae. Medical treatment with antihypertensive drugs and steroids may be helpful. We report two rare cases of retinal detachment and persistent hypertension in association with postpartum eclampsia and post-cesarean section preeclampsia. These patients had normotension throughout pregnancy. Preeclampsia or eclampsia developed after delivery, and blurred vision, headache, and reduced vision accompanied serous retinal detachment. The serous retinal detachment disappeared within 3 weeks. Good outcomes were found in the follow-up examinations in both of these cases. For women who had been normotensive at the time of delivery and then complained in the postpartum period of blurred vision, headaches, nausea and vomiting, we should consider the possibility of retinal detachment and perform fundoscopy.

Background: In the skin, the expression of androgen action is dependent on the reduction of testosterone to dihydrotestosterone mediated by the enzyme 5 alpha-reductase. Additionally, an exaggeration of this peripheral metabolism has been associated with acne in women., Methods: Fifty-two women with acne vulgaris but without hirsutism were recruited in this study, including 42 with oligomenorrhea or amenorrhea (Group 1) and 10 with regular menstrual cycles (Group 2). As a control, another 15 oligomenorrheic women without acne were also studied (Group 3). Flutamide combined with sequential estrogen-progestogen preparations was given to patients in Group 1. In Group 2, flutamide alone was administered. In Group 3, the women were treated with sequential estrogen-progestogen., Results: In Groups 1 and 2, a significant decrease in the number of inflammatory lesions was found at the end of 3 and 6 months of treatment, and even after discontinuation of therapy for 6 months. Before treatment, patients in Group 1 showed signs of biochemical hyperandrogenism, including elevated levels of serum testosterone (T), androstenedione (A), and dehydroepiandrosterone sulfate (DHEA-S), as well as a decreased level of sex hormone-binding globulin (SHBG). A decrease in circulating T and A, and an elevation in serum SHBG were found 3 and 6 months after treatment in Group 1. In Group 2, clinical improvement of acne was achieved by flutamide alone without alteration in circulating androgens (including T, A, and DHEA-S). Similarly, no change in serum androgens was observed in the women of Group 3 after treatment., Conclusion: A low dose of flutamide (250 mg/day) in association with or without estrogen-progestogen is effective for the clinical improvement of acne vulgaris in women with or without oligomenorrhea or amenorrhea. However, the effectiveness on hyperandrogenic symptoms by antiandrogens may or may not be reflected by the suppression of serum androgens.

Background: This study was designed to determine whether screening for high-risk human papillomaviruses testing could improve the detection of cervical dysplasia and cancer in assistance with conventional Papanicoloau (Pap) smears., Methods: The study was based on 114 patients with abnormal Pap smears referred for colposcopy from Feb. 1997 to Dec. 1997. The presence of high-risk human papillomavirus (HPV) DNA was determined with the Hybrid Capture method (including HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68). Cytologic examination by Papanicolaou smear was based on the Bethesda system and cervical biopsy was done via colposcopy., Results: Cytologic examination demonstrated high-grade squamous intraepithelial lesions (HSIL) in 24 patients with HPV positive (75%), low-grade squamous intraepithelial lesions (LSIL) in 38 with 61% HPV positive, and atypical squamous cells of undetermined significance (ASCUS) in 52 with 37% HPV positive. Among patients with a cytologic diagnosis of borderline abnormalities (ASCUS or LSIL), those with who were HPV positive were significantly more likely to have cervical dysplasia (both p < 0.05). The sensitivity of combined HPV assay and/or cytology for detection of noninvasive precursor (91%) was significantly greater than those of cytology (68%) or HPV assay (81%) alone., Conclusion: The addition of the hybrid capture high-risk HPV DNA assay to cytologic examination of cervical smears appears to increase the sensitivity of cervical screening. Our findings suggest that HPV DNA may be a useful adjunct marker for early detection of cervical dysplasia in women with minimally abnormal Pap smears (ASCUS/low-grade SIL).

Background: The aim of this study was to ascertain the normal range of the midtrimester maternal urine alpha-fetoprotein (AFP) concentrations in Taiwanese pregnancies., Methods: AFP was measured in the urine samples, obtained before genetic amniocentesis, from 268 women with normal singleton pregnancies between 14 and 21 weeks of gestation. Week-specific median values for urine AFP/creatinine (Cr) were calculated by weighted linear regression after log transformation and the data were converted to units in the multiple of the median (MoM). The gestational age in all cases was determined by ultrasound parameters., Results: The levels of urine AFP and AFP/Cr increased gradually with advancing gestational age. The AFP/Cr MoM values of singleton pregnancies after log transformation showed a normal distribution with a mean (standard deviation) of 0.0071 (0.3228). The median, 10th and 90th centiles of AFP/Cr were 0.98, 0.43 and 3.61 MoM, respectively. Of the pregnant Taiwanese women studied, 4.9% (13/268) and 16% (43/268) had urine AFP/Cr MoM levels less than 0.31 MoM and 0.5 MoM respectively., Conclusion: The establishment of a reference range which allows for gestational differences in AFP/Cr levels is essential for further antenatal testing.

Acardiac acephalus is a rare occurrence resulting from extensive anastomoses between the vessels of the monochorionic twins which invariably leads to death of the "perfused" twin and an estimated 50% perinatal mortality rate in the "pump" twin, due mainly to premature delivery or congestive heart failure. Once diagnosis has been documented, blocking the vascular flows between the twins has been the principle goal of treatment with the assumption that a more favorable chance of survival in the pump twin can be achieved. However, hasty surgical intervention without a well-designed preoperative evaluation may result in unfavorable outcomes. A 21-year-old nullipara was found to carry an acardiac parabiotic twin in a monochorionic twin pregnancy at 28 weeks of gestation and was referred to us from a local clinic. Expectant management based on the close monitoring of the well-being of the healthy co-twin is presented in this article along with review of published works on the management of this rare condition.

Vaginal bleeding is an uncommon and alarming symptom for children, and serious underlying causes should be excluded. Though vaginal bleeding during childhood was mostly associated with precocious puberty, the physician should keep in mind that local vaginal lesions such infectious vaginitis, vaginal trauma, and vaginal foreign bodies frequently present vaginal bleeding. A 10-year-old girl who denied any traumatic injuries or sexual abuse presented with profuse vaginal bleeding. She had normal development milestones and had no signs of thelarche or adrenarche. Her hymen was intact and the basal measurements of sex hormones including tyrotropic hormone and thyroxine were all within reference ranges. Finally, a laceration of the vaginal wall was found by vaginoscopy using a hysteroscope under general anesthesia and treated using gauze packing. We must emphasize the importance of vaginoscopy and examination under anesthesia in a child with vaginal bleeding to exclude local vaginal lesions. In addition, vaginoscopy using a hysteroscope makes the examination efficient and cost effective.

Background: The purpose of this study was to determine the reference range of maternal urine free beta-human chorionic gonadotropin (beta -hCG) concentrations between 14 and 21 weeks of gestation., Methods: We measured the concentrations of urine free beta -hCG from 268 healthy singleton Taiwanese pregnancies between 14 and 21 weeks of gestation. Results were corrected for creatinine (Cr) concentration and converted to the multiple of the median (MOM) level for the appropriate gestation. Gestational ages of all cases were determined using ultrasound dating., Results: The median levels of urine free beta -hCG and free beta-hCG/Cr had a downward trend in association with the increasing gestation age. The median, 5th, 10th, 90th and 95th centiles of free beta- hCG/Cr MOM values were 1.02, 0.20, 0.25, 2.32 and 3.38 MOM, respectively. Urine free beta- hCG/Cr MOM values showed a log Gaussian distribution with the mean and standard deviation (SD) distribution of -0.0657 and 0.3792, respectively., Conclusion: To allow for differences in free beta -hCG/Cr median values at various ages of gestation, establishment of the reference range is essential for further development of maternal urine screening for Down syndrome.

An ectopic pregnancy developing in a previous cesarean section scar is an extreme rarity among all ectopic pregnancies. Due to the difficulty of making an accurate diagnosis, this kind of ectopic pregnancy is the most dangerous and life-threatening type. A 30-year-old woman, who was gravida 4, para 3, was admitted to our emergency room with massive vaginal bleeding. She had undergone a cesarean section due to a breech birth 3 months prior to this admission. Ultrasound examination showed a pregnancy located in the low corpus uterus. The possibility of a spontaneous abortion in progress or a cervico-isthmic pregnancy were considered. Due to the massive vaginal bleeding and unstable vital signs of the patient, surgical intervention was decided upon to save the woman's life. We first performed dilatation and curettage. There was no gestational villi and severe vaginal bleeding was noted during this procedure. An emergent exploratory laparotomy was then performed, followed finally by a hysterectomy. Pathologic findings confirmed the diagnosis of a pregnancy in the previous cesarean section scar. Diagnosis, prevention, clinical evaluation and management of these conditions are discussed.

Background: Lymph node metastasis is established as a poor prognostic factor in cervical carcinoma patients undergoing primary surgery. However the optimal postoperative therapy for node-positive patients remains to be defined., Materials and Methods: To determine the role of adjuvant therapy in stage Ib-IIa cervical carcinoma patients who had pelvic node metastases after radical hysterectomy, a single institutional randomized controlled trial with factorial design, comparing concurrent chemo-radiotherapy (CT + RT) versus chemotherapy (CT) or radiotherapy (RT) alone was conducted. Study endpoints included site of recurrence, time to recurrence, relapse-free and overall survivals, and toxicity of treatment., Results: At a median follow-up of 61 months, the 6-year relapse-free and overall survival rates of the 39 patients entered into this trial were 78.2% and 85.2%, respectively. This trial was prematurely closed due to suboptimal accrual and protocol violation. It is inconclusive regarding the efficacy of CT because of the limitation of the sample size and the imbalance of prognostic features by actual treatment. A model for risk group classification of patients with stage Ib-II cervical carcinoma with pelvic node metastases from a retrospective analysis was validated by this prospective cohort. The results of this failed trial suggest that adjuvant CT alone seemed comparable to RT alone or CT + RT in survival but was associated with significantly less morbidity., Conclusion: It is warranted to consider a CT alone arm in comparison with either observation or CT + RT according to risk of recurrence in future prospective trials. However, this important issue can only be addressed by a large multicenter trial.

Lymphoepithelioma-like carcinoma of the uterine cervix is very rare. A 71-year-old woman, who had cervical cancer stage IB, presented lymphoepithelioma-like carcinoma pathologically. The neoplasm revealed an undifferentiated, nonkeratinizing carcinoma, which contained prominent vesicular nucleoli histologically. Epstein-Barr virus (EBV) DNA and HPV-16 DNA were demonstrated in cancer cells when using polymerase chain reaction. The patient underwent a radical hysterectomy with bilateral pelvic lymph node dissection and bilateral salpingooophorectomy. Her postoperative course was uneventful. The literature and pathologic findings are reviewed and discussed.

Isolated fetal ascites is a rare abnormality that can be detected prenatally by sonography. Fetuses with transient or isolated ascites were reported to have a good outcome if the specific etiology is confirmed and the appropriate treatment is given. In this report, we present 5 cases of nonimmune fetal ascites of different etiologies and obstetric managements. Fetuses that presented with generalized hydrops, chromosomal abnormalities and viral etiologies were excluded. Four of the fetuses survived without major neonatal complications, which included one chyloperitoneum, one meconium peritonitis and 2 idiopathic causes. Spontaneous resolution occurred in three cases. The one treated with prenatal paracentesis did not experience respiratory distress after birth but the other who did not undergo the procedure showed neonatal respiratory distress. The only neonatal mortality was a case involving intestinal obstruction who developed necrotizing enterocolitis four days after the surgery. Nonimmune fetal ascites can have a good outcome by using ultrasound in establishing the specific prenatal diagnosis and surveillance.

This article presents a case of left ovarian teratoma in a young child. Prompt diagnosis was made using real-time ultrasound, computed tomography (CT) and laparoscopy. The latter was used for performing tumor enucleation. We recommend that laparoscopy precede laparotomy and be done more routinely in the young patient.

A long-standing and widely used intrauterine contraceptive device has been associated with actinomycotic pelvic inflammation. The stealthy and chronic nature of the disease progresses and occasionally infiltrates adjacent organs. The non-specific symptoms of the disease, solid invasive mass and lack of marked leukocytosis, often suggest a malignancy. We present a case of advanced pelvic actinomycosis involving urogenital organs which has not been reported before. The behaviors of the disease, which mimic malignancy and urogenital manifestation, pose difficulties in diagnosis and management.

Cervical carcinoma IA1 is defined as invasive cervical cancer with measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm in diameter. It has been managed by extrafascial or modified radical hysterectomy. For young female patients who want to preserve future fertility, conservative treatment using therapeutic conization should be considered. In Taiwan, there has been little information about conservative treatment for cervical carcinoma IA1. We present 4 cases of young women with cervical carcinoma IA1 treated by conization alone. Pathological reports of all specimens demonstrated squamous cell carcinoma with free margins, stroma invasion less than 3 mm and no evidence of lymphovascular space invasion (LVSI). After 5-year follow-up with pelvic examination, pap smear, and colposcopy, there was no evidence of disease recurrence. We believe that conservative treatment for cervical carcinoma IA1 without LVSI is appropriate for selected patients to preserve future fertility.

Congenital cystic adenomatoid malformation of the lung (CCAML) is a rare pulmonary lesion, characterized by excessive overgrowth of the terminal respiratory bronchioles. Prenatal detection and serial sonographic study of fetuses with CCAML can provide information about the natural history of these lesions and reveal most of the nature history of pathophysiologic features which are likely to affect the clinical outcome. This information is crucial to the formulation of a prognosis and a management strategy. We report on four cases of CCAML, three of which involved macrocystic lesions including two cases of type I and one case of type II. Only one microcystic lesion, a type III CCAML, was identified in these patients. All of the cases were diagnosed by ultrasound between the 21 and 24 weeks of gestation. Fetal hydropic change was noted in all four cases. All of the parents opted for termination of pregnancy before fetal viability. Post-mortem examination confirmed the diagnosis in all four cases.

Background: The purpose of this study was to assess the relation of maternal age and weight on the maternal serum alpha-fetoprotein (AFP), total human chorionic gonadotropin (hCG) and free beta-hCG levels during the second trimester., Methods: We collected 419 serum samples from normal singleton pregnancies to assay serum marker levels of AFP, total hCG and free beta-hCG between 14 and 21 weeks of gestation. Maternal age at the day of delivery and maternal weight at the time of sampling were recorded in all cases. The relationship between maternal weight and multiple of the median (MoM) levels of serum markers was analysed by regression models., Results: There was an inverse trend in median MoM levels of serum markers in relation to maternal weight. No significant association between maternal age and serum marker levels was found., Conclusion: Because of its impact on serum marker levels, weight correction may be mandatory for further refinement in the maternal serum screening for Down's syndrome.

Pregnancies complicated with placenta previa and a history of cesarean section are well known to be at increased risk for placenta accreta. Bladder injury is occasionally encountered in these patients during operation. From January 1992 to December 1995, 25 obstetrical hysterectomy were performed at Chang Gung Memorial Hospital, Linkou Medical Center. Of these 25 patients three had bladder injury. Ultrasonography is a unique way to screen and detect prenatally the abnormal placentation and intraplacental lacunae. Color Doppler ultrasonic scanning further discloses that the lacunae are mainly venous spaces. Elevated mid-trimester maternal serum x-fetoprotein (MSAFP) frequently leads to a suspicion of the abnormal placentation, and magnetic resonance imaging (MRI) can clearly identify the placenta accreta/increta. Uncontrollable bleeding frequently occurs in these patients during cesarean section, warranting emergency hysterectomy. Emergency obstetrical hysterectomy should be decided upon and performed by an experienced obstetrician. Massive hemorrhage and bladder injury are the major complications encountered in such operations. We review the literature and propose a protocol of management. As the incidence of cesarean section continues to rise world-wide, the problem of placenta previa/accreta is likely to become more common. Obstetricians should be ready to face the late sequelae of today's decision for cesarean section.

Meconium peritonitis is an uncommon chemical peritonitis of a fetus resulting from antenatal bowel perforation. We reported a case of meconium peritonitis with pseudocystic formation diagnosed by color Doppler energy (CDE) at 34 gestational weeks. An echogenic substance inside a fetal abdominal mass was detected using ultrasound. By conventional color Doppler, there was minimal blood flow in the cystic wall or septums of the mass. Using CDE, bowel hyperperistalsis was observed in multiple small bowel loops and the region of intestinal loops into the mass was easily detected. Therefore, the angle independent nature of CDE will play a significant role in the early and accurate diagnosis of meconium peritonitis before birth.

Ritodrine hydrochloride, a beta 2-adrenergic receptor agonist, has been widely applied in the treatment of premature labor for many years and generally considered as a safe medication. It can however induce some serious side effects, such as pulmonary edema, myocardial ischemia, ketoacidosis, miscellaneous metabolic alterations, and leukopenia. This report presents a rare case of leukopenia in a Chinese woman as a result of low dose continuous intravenous infusion of ritodrine, in which the white blood cell count dropped rapidly and recovered quickly following the cessation of administration. The rapid and spontaneous reversal of leukopenia was most probably due to early recognition and intervention of this drug-induced side effect.

A variety of co-culture systems have been devised to enhance the human embryo development in vitro. Vero cells were selected because they can be highly controlled and are easy to handle. To evaluate the embryotrophic effects of Vero cell monolayers, when they were co-cultured with human in vitro fertilized zygotes or subzonal inseminated oocytes. Total 1695 two-pronuclear embryos resulting from in vitro fertilization were cultured with Vero cells or medium alone for 24 hours. Similarly, sixty-six two-pronuclear embryos resulted from subzonal insertion of sperm (SUZI) with co-culture starting immediately following SUZI were compared with fifty-two two-pronuclear embryos resulted from SUZI, without co-culture. The numbers of blastomere and morphology of embryos were compared between the co-culture group and control group using student's t-test. Cell numbers in each embryo were greater in the IVF/co-culture group than in the control group (4.01 +/- 1.32 vs. 3.86 +/- 1.45, p < 0.05). The rates of poor quality embryo with major fragmentation were lower in the co-culture group than in the control group(11.5% vs. 19.9%, p < 0.001, for IVF embryos; 9% vs. 27%, p < 0.005, for SUZI oocytes). Co-culture SUZI oocytes on Vero cells prior to fertilization did not positively influence embryo cleavage, but improved embryo quality. We conclude that Vero cells can enhance human embryo development; however, the period for one-day or two-day co-culture is too short to provide a maximal support. Short term co-culture did not increase implantation rates. Immediate co-culture following SUZI might somewhat rescue the microinseminated oocytes. However, a longer duration of co-culture is necessary to exert the maximal effects on embryo development and implantation.

The purpose of this study was to compare the different sperm manipulation methods on the recovery rate of motile sperm that was collected to use in the intrauterine insemination. Three hundred and thirty-five IUI (intrauterine insemination) cycle from a total of 963 treatment cycles was performed for non-peritoneal factor infertility couples. The sperm separation methods were swim-up, swim-down and Percoll gradient (since Mar. 1992). We compared the different sperm preparation methods in normal and abnormal semen analysis group. Our results show that in the abnormal semen samples (oligospermic approximately, asthenospermic approximately), the Percoll gradient method is superior to the swim-up and swim-down methods on the recovery of a higher number of total, motile and active motile spermatozoa (p < 0.05), even though the sperm quality before preparation was rather poorer than the samples prepared by the other two methods. The pregnancy rate in both groups are not statistically significant. We conclude that the Percoll gradient is an improved method for semen manipulation as it allows greater recovery of sperm with higher motility in intrauterine insemination.

To investigate the serum free beta-human chorionic gonadotropin (beta-hCG) value in women carrying Down syndrome fetus, we have retrospectively studied 11 Down syndrome pregnancies and 200 singleton unaffected pregnancies between 15 and 22 weeks' gestation. Each affected pregnancy was assigned at least 15 control cases matched with maternal age and gestational age. The median value of free beta-hCG in Down syndrome pregnancies and unaffected pregnancies was 2.56 multiples of the median (MoM) and 1.06 MoM, respectively. The mean free beta-hCG value after log transformation in Down syndrome pregnancies was 2.01 MoM that was significantly different from that of unaffected pregnancies (1.05 MoM, P = 0.024). There were 54.6% (6/11) of Down syndrome pregnancies and 5% (10/200) of unaffected pregnancies with free beta-hCG levels greater than 2.5 MoM. It is suggested that free beta-hCG may be a potentially useful and superior marker in the detection of Down syndrome pregnancies in our population.

With the aim of determining an effective therapy for adolescent women with endometriosis, the authors analyzed the results of laparotomy performed on 16 cases of female teenagers over a seven-year period. All patients, whose average age of menarche is 12.8, were diagnosed with endometriosis between two months and nine years after the menarche, with an average interval of 5.2 years. The chief symptoms are dysmenorrhea, pelvic pain and abdominal fullness. Of the three patients of unicornuate uterus with rudimentary horn, endometriosis was found only involving the adnexa on the side of the rudimentary horn, two of the three patients had absence of affected side kidney. Conservative operation including six cases of salpingo-oophorectomy and 10 cases of ovarian cystectomy were chosen followed by danazol treatment. One year to seven years after surgical treatment, two patients required subsequent conservative operation for recurrence of endometriosis and two other patients resumed dysmenorrhea. Two married women became pregnant 5 and 10 months after surgical and medical therapy respectively. In conclusion, adolescent endometriosis may occur around five years after menarche and an obstructive uterine anomaly, enhancing retrograde menstruation, increases the occurrence rate. The symptoms and treatment of endometriosis in teenage group do not really differ from that in the older women. In the treatment of endometriosis and for the prevention of recurrence, it is recommended to give three to six months of danazol after surgical treatment.

In order to establish normative median values of maternal serum total human chorionic gonadotropin (hCG) at our own laboratory, 2711 normal sera were collected from uncomplicated, singleton Chinese pregnant women, including 1705 samples measured by radioimmunoassay (RIA) between 13 and 24 weeks' gestation and 1006 samples measured by enzyme immunoassay (EIA) between 14 and 20 weeks' gestation. The hCG secretion pattern throughout midtrimester measured by RIA is similar to that of measured by both RIA and EIA have a steep drop initially and then steadily decline from 17 weeks of gestation. The total (hCG levels measured by RIA and EIA showed different normative median values and distribution. If it was measured by RIA between 14 and 20 week's gestation, there were 3.7% and 17.8% of pregnancies with serum total hCG levels less than 0.25 multiple of the median (MoM) and 0.5 MoM, retrospectively, and 11.6% and 5.5% among them with serum levels above 2.0 MoM and 2.5 MoM, respectively. When it was measured by EIA, there were 0.7% and 9.2% of pregnancies with serum total hCG levels less than 0.25 MoM and 0.5 MoM, respectively, and 8.9% and 3.7% among them with serum levels above 2.0 MoM and 2.5 MoM, respectively. Accurate and satisfactory interpretation of maternal serum screening for Down syndrome depends on establishment of a well-developed normative median value for each week of gestation. Any laboratory intends to provide hCG for maternal serum screening should have its own reference data by its own immunoassay method.

The efficacy of intrauterine insemination with husband's semen (AIH) is well established for some types of infertility. Results that had been reported previously were Dwing difficult to assess owing to the low number of patients or treatment cycles as well as an inadequate definition of the indications in most cases. In this study, we report our experience with intrauterine insemination (IUI) using post-treated sperm suspension from husband's semen in the treatment of infertility. A total of 328 treatment cycles were completed from January to December in 1991. The indications for AIH/IUI were male infertility (130 cycles), unexplained infertility (87 cycles), sex selection (72 cycles) and anovulatory disorder (39 cycles). Sixty-eight pregnancies were achieved. The clinical usefulness of AIH/IUI with or without concomitant hMG regimens were established according to diagnostic subgroups. In our results, the cycle fecundity of pregnancy was higher in patients with ovulatory disturbance. The importance of sperm motility confirmed by our results that have compared by the serial sperm parameters. The motile sperm count may appear to be a highly consistent parameter that serves as a sensitive indicator of sperm function and correlation of successful pregnancy in our results. In conclusion, this study indicates that AIH with controlled ovarian hyperstimulation can result in higher viable pregnancy rate, and it is also a non-invasive and relatively easy procedure. We believe that this is a transient useful method for the treatment of non-organic infertility, prior to any attempt of aggressive assisted reproductive procedures.

Clinical and histopathological features of 12 patients with malignant mixed müllerian tumor of the uterine corpus presenting to Chang Gung Memorial Hospital from January 1988 to September 1993 were retrospectively investigated. The age distribution ranged from 43 to 76 years with a median of 56, and post-menopausal bleeding was the most common symptom in these patients. There was 60% (6/10) of discrepancy in histologic diagnosis between the specimens of dilatation and curettage and that of hysterectomy. All patients received total hysterectomy and bilateral salpingo-oophorectomy, and 10 with retroperitoneal lymph node dissection. Nine patients received cisplatin based chemotherapy, one received radiation only, one received sequential chemotherapy and irradiation, and one underwent concurrent chemoradiation as adjuvant. Two-year survival in patients with stage I-II was 70% (95% C.I.: 34%, 100%) and that of stage III, 25% (95% C.I.: 0.67%). There was 42% (5 of 12) progression/recurrence rate, all developed within 2 years. An effective adjuvant chemotherapy after comprehensive surgery including a total abdominal hysterectomy, bilateral salpingo-oophorectomy and lymph node dissection may be needed for a satisfactory improvement in the patients' survival.

Pelvic inclusion cyst is one of the complications of major abdominal surgery. Treatment of the symptomatic mass is either surgical or needle aspiration. However, recurrence of the condition is still not uncommon. Repeated surgery or aspiration could result in serious morbidity. We report two cases of recurrent pelvic inclusion cyst which were successfully treated with transvaginal aspiration and sclerosing therapy with starch powder from surgical gloves and normal saline solution. The aspirations were guided by transvaginal ultrasound and on local paracervical anesthesia. Starch and normal saline solution were injected through the aspiration needle for irrigation three times. One patient with a large cyst needed two treatment courses, the other only one. Both patients had no discomfort both intra- and postoperatively. A Follow-up ultrasonography proved no recurrence to date.

We present the first recorded case which received a combined laparoscopic hysterectomy, right salpingo-oophorectomy and cholecystectomy during one anesthetic period in Taiwan. This procedure was done to treat the coexisting benign lesions of the uterus, ovary, and the gall bladder. Postoperative pathological diagnoses was myoma, an ovarian hemorrhagic corpus leutum cyst, cholelithiasis, and cholecystitis. Estimated blood loss was less than 150 ml for the combined procedure. With the total operation time being 135 minutes. The patient recovered soon and could take a regular diet and walk without assistance 20 hours after operation. She discharged 4 days later and returned to work 5 days after discharge. We think for well trained laparoscopists, a cross-specialty cooperation between a gynecologist and a general surgeon to treat coexisting lesions of the uterus and the gall bladder is a safe, feasible, and beneficial procedure.

This paper presents four recent cases of complications resulting from of a total 130 cases of laparoscopy-assisted vaginal hysterectomies performed at Chang Gung Memorial Hospital from March 1991 till January 1993. These included two cases of bladder injury, one case of vessel laceration and one case of colon injury. In addition, the literature about complications occurring at laparoscopy are reviewed and classified. This paper will: 1. present precautionary measures for avoiding intraoperative complications; 2. describe management of complications.

Maternal serum alpha-fetoprotein (MSAFP) screening has been widely used and proven valuable in the prediction of a variety of fetal disorders. Any laboratory intending to provide MSAFP screening needs to establish its own reference data. In order to establish a normal MSAFP median value at our own laboratory, 5256 samples of MSAFP were collected from uncomplicated, singleton pregnant women between 13 and 24 weeks' gestation. The MSAFP median levels steadily rise with advancing gestation about 16% per gestational week in average. There were 0.17% and 4.4% of the pregnancies with serum AFP levels less than 0.25 multiple of the median (MoM) and 0.5 MoM respectively, and 4.22% and 1.66% with serum levels above 2.0 MoM and 2.5 MoM. Accurate and satisfactory interpretation of MSAFP screening should be emphasized in the establishment of a well-developed normal median value.

The finding of low implantation of placenta during midtrimester is not uncommon. It does not constitute an immediate obstetric emergency, but rather demanding serial and thorough follow-up. Previous uterine trauma and scarring caused by Caesarean section is a significant predisposing factor, while the roles of maternal age, gravidity, parity, sex of newborn are controversial. Placenta previa patients have a tendency to develop antepartum hemorrhage and preterm labor. Neither IUGR nor congenital malformations are associated abnormalities in our study. The rate of cesarean section in patients with placenta previa has increased, but the risk of perinatal morbidity has not increased. "Migration" means the dynamic relationship between the placenta and internal O.S., which occurred in 79.6% cases overall, especially in the subgroup of low-lying and marginal placenta previa. The "migration" does not protect patients from operation, nonetheless, the defined "placenta previas" are not all destined to cesarean section. Ultrasonography is a helpful diagnostic tool, via abdominal or vaginal route, and is a practical guide of expectant management.

The tenet that a combination of human follicle-stimulating hormone (hFSH)/human menopausal gonadotropin (hMG) after pituitary desensitization with GnRH analogue improves follicular recruitment was assessed by treating infertile women in an in vitro fertilization (IVF) program. The participants of this study were one hundred sixty-six infertile patients on IVF program who received FSH/hMG, or hMG alone superovulation protocol after pituitary desensitization. Fertilization rate, cancellation rate, mean number of follicles, and endometrial thickness did not differ between the two groups. But in the FSH/hMG group, total oocyte per retrieval, embryo score, implantation rate, and viable pregnancy rates were slightly higher although the increase was not significant. Furthermore, the rate of preovulatory oocytes per retrieval, Estradiol (E2) level, embryos frozen, and embryos transferred were significantly higher in this group. This suggested that increasing the exogenous FSH/LH ratio in ovulation induction may result in a higher recovery of fertilizable oocytes and a subsequent potential for improvement in IVF outcome.

Using continuous administration of gonadotropin releasing hormone analogues (GnRH-analogue) to induce a hypoestrogenic state and amenorrhea, leading to uterine fibroid volume reduction, has been reported to be successful and acceptable. Only a few adverse effects related to the therapy have been reported. We report a case of acute onset of abdominal pain, increased sedimentation rate and low grade fever during treatment with intranasal administration of Buserelin acetate. An emergent myomectomy was performed to remove an infarcted intramural myoma. We propose that acute ischemia of a large leiomyoma, especially during the postpartum period, is a noticeable complication during medical treatment with buserelin acetate for uterine leiomyoma.

Meconium peritonitis is usually the result of prenatal bowel obstruction with subsequent perforation, then the contents spread into the peritoneal cavity, which results in a sterile inflammatory reaction. The incidence ranges from 1/1500 to 1/2000, if without prenatal diagnosis and planned postnatal treatment, the mortality rate is as high as 62%. We describe three children, two with surgically, one with autoptically confirmed meconium peritonitis. All had abnormally prenatal ultrasonographic examinations. The first fetus showed a large 10 x 11 cm intra-abdominal mass with floating echogenic substances inside and with an echogenic rim. The second showed increased echogenicity with dilated bowel in abdominal cavity in one of the twin, and the third had an intra-abdominal cyst with several echogenic bands inside, fetal ascites was also noted. It is remarkable that the ultrasonographic findings were different in the three children. Two of the three children survived postoperation, one died 3 hours later after induction out at 31 weeks of gestational age due to multiple congenital anomalies.

Twenty postmenopausal women with tuboovarian abscess were surgically managed at CGMH during 1981 to 1991. Fever with lower abdominal pain were the most common symptoms and signs. Laboratory, sonographic & roentgenologic studies helped in detecting and in making a correct preoperative diagnosis of the origin of the inflammatory complex. Half of the patients had postmenopausal bleeding or discharge. Six tuboovarian abscesses were ruptured at the time of surgery and of these had prolonged hospitalization due to complications. Among the six complications, 2 suffered from intraoperative bowel injury, 2 had postoperative wound infection, 1 colonocutaneous fistula and 1 sigmoid stricture. Abdominal total hysterectomy was tried in all the cases but the surgical procedure was changed to subtotal hysterectomy in two and bilateral salpingo-oophorectomy in one. Septic condition and suspicion of ruptured abscess are indications for immediate operation. No major medical complication developed in the post-operative period. However, the early detection and treatment of unruptured tuboovarian abscess had less surgery related complications and had a shorter mean length of hospitalization.

Rhabdomyosarcoma is the most common soft tissue sarcoma in childhood, but it is rare in young adults. It usually occurs in the pelvis or genito-urinary tract. We report a case of abdominal embryonal rhabdomyosarcoma who received a combined treatment modality with radical pelvic surgery and combination chemotherapy of vincristine, actinomycin-D and cyclophosphamide (VAC). She is well with no evidence of tumour recurrence for 3 years after primary surgery.

An association between low maternal serum alpha-fetoprotein (MSAFP) and fetal trisomy has now been thoroughly documented. The mechanisms resulting in low MSAFP are still unclear. In order to determine whether the low values of MSAFP in autosomal trisomies are associated with smaller fetal weights, we compared 11 fetuses with Down syndrome (trisomy 21), 4 with trisomy 18, with 45 normal fetuses. All of them are aborted in the second trimester of pregnancy. No significant difference in the weight distribution between fetuses with Down syndrome and control fetuses was found. In contrast, as compared with the control fetuses, fetuses with trisomy 18 had a significant lower weight distribution. The mean value of MSAFP was 0.72 +/- 0.26 MoM for those with Down syndrome and 0.51 +/- 0.33 MoM for fetuses with trisomy 18; both results being significantly lower than that of normal control (1.01 +/- 0.28). The mean value of amniotic fluid AFP was 0.63 +/- 0.23 MoM for fetuses with Down syndrome. This value was significantly lower than those of the fetuses with trisomy 18 and normal controls (1.02 +/- 0.09 and 1.02 +/- 0.30). A linear relationship between MSAFP and fetal weight was found in normal fetuses at a given gestational age but was not found in trisomy pregnancy. Fetal weight cannot be used to explain the reason for low MSAFP in Down syndrome pregnancy but may partially account for the lower levels noted in fetuses with trisomy 18.

The ovum donation program at Chang Gung Memorial Hospital currently confronts the difficulty of limited oocyte resources. The oocytes might be donated from the surplus oocytes of IVF patients. However, after the successful introduction of embryo cryopreservation, patients preferred to have their surplus embryos cryop-reserved and thus, few surplus oocyts were available for donation from IVF program. In addition, official policies discourage use of oocytes donated by consanguineous relatives of either one of the recipient couple or for financial rewards. Among the first three oocytes recipients, with ovarian failure, one chemical pregnancy resulted. Oral premarin and transvaginal and intramuscular progesterone were administered as hormone replacement. The fourth recipient, who had had bilateral oophorectomy, received transdermal estradiol patch (Estraderm) and transvaginal progesterone (Utrogestan) as hormone replacement. The Estraderm/Utrogestan protocol became standard in later cases since the first ongoing pregnancy was achieved in patient 4. We feel this protocol satisfies the required ample levels of hormone replacement for ovum donation.

A modified technique that requires fewer specialized instruments for laparoscopic cystectomy is demonstrated. Twelve consecutive cases of laparoscopic management of the ovarian tumors are reported. Patients were not included if there was any suspicion of malignancy. Laparoscopic management of the ovarian tumors included ovarian cyst (N = 8) and endometrioma (N = 4). No intraoperative or postoperative complications occurred. The average hospital stay was 2.6 days. The whole tumor was removed through an infraumbilical incision. Laparoscopic cystectomy is a cost effective and safe procedure.

46,xy pure gonadal dysgenesis is a rare disorder, which is characterized by female phenotype, infantile female external genitalia, deficient secondary sexual development, hypoplastic uterus and fallopian tubes, and streak gonads. A 17-year-old female phenotypic patient was admitted due to primary amenorrhea, who also had poor breast development, deficient axillary and pubic hairs, and infantile female external genitalia. Lymphocyte culture of peripheral blood for chromosome study revealed 46,XY normal male karyotype. Endocrine evaluation demonstrated low estrogen, high LH and FSH levels, and normal testosterone level of female range. According to the high risk of germ cell tumor occurrence in 46,XY gonadal dysgenesis, bilateral salpingo-oophorectomy and total hysterectomy were performed. Pathology of the left ovary revealed gonadoblastoma accidentally. Thereafter, she received regular hormone therapy and had generally felt well. Secondary sexual development was noted one year later.

Malignant mixed müllerian tumor of the fallopian tube is extremely rare, with less than 50 cases recorded in the English literature. Another case is reported and discussed. This 66-year-old female patient complained of profuse watery vaginal discharge for one month. Vaginal cytology was positive for malignancy while the endometrial curettage and cervical biopsy were both negative. Gynecologic sonography revealed a left adnexal mass of 6 cm in diameter. She underwent exploratory laparotomy after complete oncologic survey. The main tumor was confined to one tube but the peritoneal washing cytology was positive for adenocarcinoma cells. She tolerated the maximal debulking surgery very well but refused to receive adjuvant chemotherapy. Pathology proved that the tumor was composed of poorly differentiated adenocarcinoma and sarcoma. There were focal areas of rhabdomyoblastic differentiation with cross striation in immunoperoxidase stain. Carcinomatosis peritonii occurred 12 months after primary surgery and she expired one month later.

A research of mouse embryo cryopreservation was carried out in our department in order to establish the clinical service of human embryo cryopreservation. Mouse embryos were stored in glass vials using 1.5M propanediol (PROH) or 1.5M dimethyl sulfoxide (DMSO) as cryoprotectants and we used a modified four-step equilibration method to minimize osmolarity shock. We divided the 1490 embryos into two phases and compared phase 1 to phase 2. After achieving more sophisticated handling techniques and more accurate timing of each procedure, the survival rate (25% vs 59.8%) and stage advancing rate (5.2% vs 33.5%) were all improved in phase 2. The proportion of frozen embryos developing to hatched blastocysts was significantly increased from 14.5% to 56.7% in the 4-cell embryo groups compared to the 2-cell embryo groups. Two kinds of cryoprotectants were used in the 4-cell embryos and the results showed no difference in the post thaw survival rate but a better blastocystic development in the propanediol group (64.0% vs 41.5%). The results obtained from this study have encouraged us to initiate a major clinical trial of the technique in our IVF programs. Two pregnancies have been established upon the transfer of cryopreserved embryo and two normal healthy infants have already delivered at our hospital.

From June 1978 to June 1990, there were 41,989 deliveries, 13,396 cesarean sections and 15 emergency obstetric hysterectomies at Taipei Chang Gung Memorial Hospital. The incidence of emergency obstetric hysterectomy is 36/100,000 deliveries. The mean age of patients is 31.7 years old. The indications for hysterectomy were placental disorder (60.0%), uterine atony (26.7%), and uterine rupture (13.3%). The present series showed that 14 cases had total abdominal hysterectomy, while only one case had a subtotal hysterectomy. Total hysterectomy should generally be performed unless maternal instability mandates a more expeditious subtotal hysterectomy. The most common postoperative complication included unknown fever and urinary tract infection. For those four cases of post-cesarean hysterectomy, conservative treatment was tried but failed. All cases presented with hypotension (less than 80/60 mmHg), tachycardia (greater than 100 times/min) and with a mean hemoglobin of 9 mg% during the observation period. In these patients, blood loss, operating time and length of hospitalization was increased when compared with a group of 7 patients undergoing cesarean hysterectomy. In patients with placenta accreta, who are candidates for cesarean hysterectomy, initial hypotension, tachycardia and shock developed during cesarean section. It must be emphasized that conservative aggressive measures to control obstetric hemorrhage remain the mainstay of therapy, but emergency hysterectomy played the life-saving role with which every practitioner of obstetrics must be familiar and keep in mind.

Two hundred and fifty-five patients underwent forceps deliveries in Chang Gung Memorial Hospital from January 1, 1985 to June 30, 1990. There was neither maternal nor perinatal mortality related to this procedure during this period; and the perinatal outcome was good without sequela. In the past three years, cesarean section took the place of forceps delivery in some cases with acute fetal distress and malposition. As a result, maternal problems became the most common indication for forceps delivery during that period. Fourth degree laceration of the perineum was the major maternal complication, occurring in 22.4% of total forceps deliveries. Postpartum voiding problems continued to be another complication after forceps delivery, accounting for 7.0%. Either fourth degree laceration of the perineum or postpartum voiding difficulty could be prevented to a certain extent if the forceps were handled delicately in an experienced hand and there was early diagnosis with prompt management of voiding dysfunction.

This study was undertaken to estimate the cesarean delivery rate in Chang Gung Memorial Hospital (CGMH) and to determine whether the reasons for the rising rate have changed during the past 6 years. Since 1984, 43% of the rise in the cesarean rate was due to repeat cesareans, 29% due to dystocia, and 15% due to fetal distress. At the same time, the cesarean delivery rates due to abnormality of position and placentation dropped by 2% in either condition. The rate of cesarean delivery among those with a previous cesarean was 98%. In the future, if the number of vaginal deliveries after cesarean increases, then the overall cesarean delivery rate will decrease or stabilize.

We report an unusual case of a 70-year-old female with rhabdomyosarcoma of the uterus following radiotherapy for her stage IIIb cervical carcinoma 5 years ago. To our knowledge this may be the first case of rhabdomyosarcoma originating from the uterus following cervical cancer radiotherapy.

A rare case of Müllerian adenosarcoma occurred in the uterine endometrium of a 40-year-old woman. Histologically, the tumor was composed of an admixture of benign-appearing glands and a sarcomatous stroma. This neoplasm appears to have a relatively low malignant potential in contrast to the more aggressive form of malignant mixed Müllerian tumor. Our case was treated with hysterectomy and radiation. She was well after two and a half years.