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This study assesses the relative risks of first trimester transcervical chorionic villus sampling (CVS) versus midtrimester amniocentesis performed between April 1986 and March 1988. The most common indication for prenatal diagnosis was advanced maternal age. We discovered 5.1% chromosomal aberrations in CVS compared to 1.0% in amniocentesis. Bleeding was the most frequent early complication, and only 1 case had major hemorrhage with subsequent spontaneous abortion. The fetal loss rate (gestational age less than 28 weeks) was 4.5% in CVS versus 1.2% in amniocentesis, which was not significantly different from the background fetal loss rate reported in normal pregnancies after an 8-week gestational age. Three cases of fetal loss after CVS were probably procedure-related; 1 case had spontaneous abortion and 2 cases had chorioamnionitis. Therefore, we considered that the causal relationship between CVS and the infection was highly probable. The clinical pregnancy outcome indicated that there were no differences in overall perinatal mortality, Apgar score, body weight, body length, gestational age at delivery, intrauterine growth retardation, placenta weight and placental disorders between the CVS group and the amniocentesis group. The pregnancies did not reveal any specific effects of the prenatal diagnostic procedure, but a long-term pediatric follow-up is needed.

The diagnosis of ventral abdominal wall defect can now be made prior to birth. With this diagnosis, the family can make decisions and a planned optimal management can lead to a successful outcome. There were 31 cases of ventral wall defect identified at Chang Gung Memorial Hospital (CGMH) from January 1979 through March 1988. Twenty of them were classified as gastroschisis; among them, 17 (85%) were born in outside clinics and none of them had associated anomalies. In contrast, among 11 cases of omphalocele, there was a lower frequency of transferred cases (27% vs 85%), and 4 cases had additional defects, including two multiple anomalies and two bladder exstrophies. There were no significant differences between gastroschisis and omphalocele in the mortality rate (30% vs 36%), in the incidence of intrauterine growth retardation (IUGR) (30% vs 27%) and in the Cesarean section rate (15% vs 18%). All 4 cases of prematurity (less than 36 weeks of gestational age) expired after delivery and 2 of these had body weights of less than 1500 g. Three out of 5 cases delivered by Cesarean section expired; the mortality (60%) was higher than that of vaginal delivery (28%). All 3 cases were gastroschisis, 2 of them were transferred from outside clinics and all expired due to sepsis. The diagnosis of ventral wall defect should be made prenatally, with obstetric ultrasonography, maternal serum alpha-fetoprotein screening and fetal karyotyping. Therefore, fetal transport in utero to a referral center and optimal perinatal care for those fetuses with potentially correctable lesions can be well planned.

Bone mineral density (BMD) was measured in 17 patients with gonadal dysgenesis, 21 patients with premature ovarian failure, 14 patients with hyperprolactinemia, 23 patients postoophorectomy and 41 normal healthy women. Each group was divided into two subgroups, on the basis of whether or not they were receiving estrogen replacement therapy. Linear regression analysis showed a significant loss of BMD at a rate of 0.006 g/cm2 per year in the lumbar spine of normal healthy women. The distribution of individual values in each study group was near or within normal confidence limits, except for the group with gonadal dysgenesis. The mean BMD of each group without estrogen replacement therapy was significantly less than that of the control group. There was a significant correlation between the duration of amenorrhea and BMD values in the groups with premature ovarian failure and postoophorectomy. These results indicate that BMD, measured by dual photon absorptiometry, was reduced in amenorrheic patients, especially in patients with gonadal dysgenesis. Estrogen replacement therapy was able to decrease the severity of bone loss, but failed to increase the bone mass. Dual photon absorptiometry (DPA) is a simple, effective, and accurate tool for assessing the severity of osteoporosis and monitoring the effect of therapy.

Oocyte retrieval for in vitro fertilization and embryo transfer (IVF/ET) through the cul-de-sac under the guidance of a vaginal sector scanner was performed on 12 patients and compared with the previous laparoscopical oocytes retrieval for in vitro fertilization. Using a transvaginal sector scanner with puncture guide line, the needle was introduced through the posterior fornix of the vagina into the ovary. Vaginal sonography obviously has more benefits than the conventional laparoscopic method as the patients can be rid of the risk of repeated laparoscopy, can have less anesthetic and it is not necessary to have CO2 pneumoperitoneum, etc. When this method is compared with the transvesical approach, the transvaginal method does not require a full bladder, and has a shorter distance between the transducer and the follicles so it can provide better patient acceptability and better sonographic images which can increase the accumulated success rate. The recovery rate of oocytes was 8.83 per cycle which equals a mean recovery rate of 84%. The clinical pregnancy rate was 25% per retrieval cycle and 33.3% per embryo transfer. The results were not worse than those by laparoscopy and the transvesical method. This procedure is less time-consuming and has less blood loss than the other methods. We believe that, after a period of progression, IVF/ET can be performed in an outpatient setting with decreased risks and expenses of laparoscopy and general anesthesia.

Four cases of severe preeclamptic patients with the findings of hemolysis (H), elevated liver enzymes (EL) and a low platelet count (LP) were presented. Maternal mortality occurred in two of the four cases with one experiencing liver rupture. Intrauterine fetal death occurred in 3 cases. The entity has been termed the HELLP syndrome. The high maternal and perinatal mortality of our cases was mainly due to the severe coagulopathy associated with the HELLP syndrome. The practicing obstetrician must be knowledgeable about this severe consequence of toxemia in pregnancy and aggressive management is essential to improve maternal and perinatal outcome.

A review is presented summarizing the IVF-ET, GIFT and combined IVF-ET-GIFT experienced at Chang Gung Memorial Hospital. Since the building of an aseptic dust free laboratory next to the operation room, the clinical pregnancy rate has been 12.2% per embryo transfer in IVF-ET, 16.7% in the GIFT program and 30.0% in the combined IVF-GIFT program. The overall clinical pregnancy rate was 14.9%. The overall pregnancy rate appeared to be independent of the causes of infertility, be it tubal factor, endometriosis or unexplained infertility. It was lower in couples with male factor or combined factors. The different regimens for follicular stimulation were hMG-hCG, clomiphene-hMG-hCG and FSH-hMG-hCG. No one regimen showed a better pregnancy rate than the others. The methods of oocyte retrieval were laparascopy, laparotomy, transbladder ultrasound-guided, and transvaginal ultrasound-guided retrieval. There were 4.53 oocytes retrieved pertreatment cycle. The transvaginal ultrasoundguided oocyte retrieval has greatly simplified the procedures in the IVF-ET program. The patient selection was important not only for the indications but also for the methods of IVF-ET, GIET and combined IVF-GIFT.

Factors affecting pregnancy rates in gamete intrafallopian transfer (GIFT) and in vitro fertilization (IVF) were evaluated. Higher pregnancy rates were found when more mature oocytes were recovered (6.2 +/- 2.5 vs 3.8 +/- 3.0) and more oocytes (4.6 +/- 1.0 vs 3.3 +/- 1.2) or zygotes (4.7 +/- 1.4 vs 3.0 +/- 1.7) were transferred. Ultrasound-guided follicular aspiration was successful for in vitro fertilization and had a pregnancy rate (14.3%) comparable to the laparoscopic approach (13.3%). Laparotomy for correction of pelvic pathology concomitant with oocyte retrieval should be used cautiously despite the high preliminary pregnancy rate (42.9%). Failed fertilization of the surplus oocytes left after gamete intrafallopian transfer did not mean a poor chance of pregnancy (27.6%). The combined treatment of gamete intrafallopian transfer and in vitro fertilization may have a higher chance of pregnancy (43.5% vs 21.4% in GIFT and 13.3% in IVF), and more multiple pregnancies (40.0% vs 22.2% in GIFT and 16.7% in IVF). Cycles with spontaneous LH (luteinizing hormone) surges, detected by daily morning urine samplings, need not be aborted and the timing of ovum recovery should be individually evaluated.