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Purpose To determine the influence of a patient education and care program on the quality of life (QOL) of female patients undergoing non‐assisted reproductive technology (ART) fertility treatment. Methods Participants completed the MOS 36‐Item Short‐Form Health Survey and fertility QOL (FertiQoL) questionnaires at baseline and at 3, 6, and 12 months of treatment. The responses of patients who underwent three sessions of the program (at baseline, 3 months, and 6 months of treatment) were compared with those of patients who did not receive the program. Results This study compared 69 patients who received an additional care program with 104 patients in the control group, all from 13 facilities. Treatment FertiQoL responses (p = 0.004) and treatment tolerability (p = 0.043) differed between the program and control groups at 3 months using the repeated measures mixed model. The cost of treatment per pregnancy was lower in the program group than in the control group. Conclusion The patient education and care program provided by reproductive fertility specialists or fertility nurses during non‐ART fertility programs improves patient satisfaction.

Background The presence of uterine endometrial polyps is associated with not only abnormal uterine bleeding but also infertility, so the use of hysteroscopic polypectomy has been increasing. This operation is considered to increase cost-effectiveness when performed prior to infertility treatments. However, there are typical problems to consider, including the possibility of spontaneous regression of the polyp and the duration of complete endometrial wound healing after surgery. Meaningless interventions must be avoided, when possible. Therefore, data acquisition and analysis of various findings obtained from surgery have become important for improving treatment procedures and patient selection. To estimate the spontaneous regression rates and contributions of multiple factors to uterine endometrial polyps during the waiting period (approximately 2–3 months) before hysteroscopic polypectomy, we performed a multivariate analysis of data from the records in our hospital. Methods The medical records of 450 cases from September 2014 to April 2021 in our hospital were retrospectively reviewed under the approval of our Institutional Review Board. We included all cases of hysteroscopic polypectomy with postoperative pathological diagnosis. We defined cases as having a “spontaneously regressed polyp” when the target polyp was not detected by postoperative pathological examination. We extracted data on the following ten factors: “Advanced age” (≥ 42 years), “Small polyp” (2), “Nulliparity,” “Single polyp,” “Infertility,” “Hypermenorrhea,” “Abnormal bleeding,” “No symptom,” and “Hormonal drug use.” We also classified cases into five groups according to the size of the polyp (≤ 4.9 mm, 5.0–9.9 mm, 10.0–14.9 mm, 15.0–19.9 mm, and ≥ 20.0 mm) and determined the frequency of spontaneously regressed polyp in each group. Results After exclusion of cases with insufficient data or other diseases, such as submucosal leiomyoma, 424 cases were analyzed. Among them, 28 spontaneously regressed polyps were identified, and the highest frequency of spontaneously regressed polyp was detected among the cases with polyps measuring 5.0–9.9 mm (16.4%). On multivariate analysis of the ten factors, “Small polyp” and “Hormonal drug use” were found to significantly impact the frequency of spontaneously regressed polyp. Conclusions On the basis of the factors identified in this analysis, the indications for observation or medical therapy adapted to small polyps might be expanded.

Background The application of laparoscopic surgeries has been increasing, and various uterine diseases in addition to leiomyoma/adenomyoma have become indications for total laparoscopic hysterectomy (TLH). Therefore, data acquisition and analysis of TLH procedures, including TLH for rare uterine diseases, have become important for improving surgical procedures and patient selection. To determine the prevalence of and risk factors for the occurrence of intraoperative and postoperative complications of TLH, we performed a multivariate analysis of the records in our hospital. Methods We retrospectively reviewed the medical records of 323 patients who underwent TLH for the treatment of leiomyoma/adenomyoma (278 cases), low-grade (pre)malignant uterine tumours (40 cases) and other rare uterine diseases (5 cases) from January 1, 2015, to December 31, 2019. Of the rare uterine diseases, one case of caesarean scar pregnancy for which TLH was performed is introduced as a case report. To assess the effects of 11 representative factors, including patient characteristics, uterus and leiomyoma sizes, indications for TLH and others, we performed a multivariate logistic regression analysis. Results Among the 323 cases, 20 intraoperative complications and 15 postoperative complications were reported. In the multivariate analysis, “ovarian tumour” and “heavy uterus” were positively associated and “nulliparity” was negatively associated with intraoperative complications. There were no significant risk factors for postoperative complications. The only risk factor for operative complications directly related to the resected uterus was “heavy uterus”. Therefore, we could perform TLH relatively safely for patients with other indications besides leiomyoma/adenomyoma. Conclusions Considering the factors detected in this analysis, the indications for TLH may be expanded. Owing to the increase in TLH for indications other than leiomyoma/adenomyoma, a more accurate determination of the treatment approach can be achieved.

In order to diagnose endometrial cancer preoperatively, outpatient endometrial biopsy with a curette is frequently performed owing to its convenience. However, in some cases, gynecologists fail to diagnose endometrial cancer via outpatient endometrial biopsy because of the cancer’s distribution in the uterus and its consistency. A 57-year-old Japanese woman (gravida 4 para 4) presented with a 6-month history of light but intermittent postmenopausal vaginal bleeding. A malignant uterine tumor was strongly suspected after imaging using ultrasound examination and magnetic resonance imaging; however, a precise pathological diagnosis was not achieved despite multiple outpatient endometrial biopsies with the aid of office hysteroscopy. Based on an endometrial biopsy obtained using a cutting loop electrode on an 8.3-mm operative resectoscope, we reached a diagnosis of endophytic-type endometrial cancer, which is in accordance with the final pathological diagnosis after abdominal hysterectomy. Three months after her first visit to our hospital, total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic/para-aortic lymph node dissection were performed. Macroscopically, the endometrium was atrophic, and there was no obvious mass in the uterine cavity; however, microscopically, the cancer cells mainly existed in the deep myometrium and the final diagnosis was International Federation of Gynecology and Obstetrics (FIGO) stage IB endometrial cancer. Operative biopsy of the uterine endometrium and deep myometrium using hysteroscopy confirmed an accurate preoperative diagnosis of uterine endometrial cancer specifically of the endophytic type.

AIM The aim of this study was to identify predictive factors for emergent surgical interventions in patients with ovarian endometriomas hospitalized for pelvic inflammatory disease (PID). METHODS We retrospectively identified 22 patients with ovarian endometriomas who were hospitalized to manage PID. Patients were divided into two groups: those who required emergent surgery after failed antibiotic therapy (emergent surgery group, n = 6) and those who were discharged with successful antibiotic therapy (conservative group, n = 16). Logistic regression analysis was performed to analyze the factors associated with emergent surgery. RESULTS Patients in the emergent surgery group were significantly more likely to have intrauterine or intrapelvic procedures before the onset of PID compared to those in the conservative group (83% vs 38%, odds ratio 8.33, 95% confidence interval 1.02-181.3; P = 0.048). The mean interval between the onset of PID symptoms and the commencement of parenteral antibiotic therapy was significantly longer in the emergent surgery compared to the conservative group (6.5 vs 1 day, odds ratio 1.28, 95% confidence interval 1.01-1.75; P = 0.041). CONCLUSION A history of an intrauterine or intrapelvic procedure before the onset of PID was more likely to result in emergent surgery. A longer interval between the onset of PID symptoms and the commencement of parenteral antibiotics was also associated with emergent surgery. These findings could help to identify patients with ovarian endometriomas hospitalized with PID at higher risk of emergent surgical intervention.

Background: We compared the revised American Society for Reproductive Medicine (ASRM) scores determined during laparoscopic surgery to evaluate the effect of the location of the endometrioma (right vs. left ovary) on the severity of endometriosis. Methods: The medical records of 151 patients, including 58 right-sided and 93 left-sided cases, who underwent an initial laparoscopic surgery for unilateral ovarian endometrioma were reviewed retrospectively. We extracted the ASRM scores determined during surgery and some representative factors related to endometriosis that are separate from the tumour characteristics, such as the coexistence of uterine fibroids, adenomyoma, or other ovarian tumours, a history of use of assisted reproductive technology (ART), and tumour marker values. A statistical analysis was performed to assess the impact of each factor. We classified the ASRM scores into 4 categories to compare the tendency towards endometrial lesion spread with a focus on the “sidedness” of the endometrioma. We defined contralateral endometrial lesion (CEL), Douglas pouch endometrial lesion (DEL), same endometrial lesion (SEL) and peritoneal endometrial lesion (PEL). Results: The ASRM scores of patients with a right-sided endometrioma were significantly higher than patients with a left-sided endometrioma (41.5 ± 22.1 points vs. 32.9 ± 15.8 points, p

Aim To evaluate the clinical relevance of robotic-assisted surgeries (RAS) for gynecologic malignancies in a Japanese multi-institutional cohort. Methods A retrospective review of perioperative outcomes of 357 gynecologic RAS procedures was conducted in 24 hospitals accredited to perform RAS by the Japanese Society of Obstetrics and Gynecology (JSOG) over a 4-year period, January 2014 to December 2017. Results More than 25 (high), 10-24 (middle) and less than 10 cases (low) were enrolled from 3, 8 and 13 hospitals, respectively. A total of 247 patients underwent RAS for malignant indications. Radical hysterectomy (RH) was conducted for 200 patients, while para-aortic node excision (PAN) for 47 patients. RAS with RH or PAN was more feasible in high-volume centers with significantly shorter operation time and lesser blood loss than that in middle-volume centers. The total rate of perioperative injury and complications in RAS with PAN reached 33.3% in high-volume centers, which was almost equal to those in middle-volume centers (35.5%) but much higher than RAS without PAN (8.5%). Conclusion Perioperative surveillance demonstrated high feasibility of gynecologic RAS procedures conducted in JSOG accredited hospitals for these 4 years. It is mandatory for RAS conducting hospitals to have careful attitudes to realize their learning curves in conducting advanced procedures.

Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine, in collaboration with four other medical societies, launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all clinical questions and recommendations were shown in supplementary information). A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. A total of 108 questions based on nine subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

Background: Since acute abdomen requires accurate diagnosis and treatment within a particular time limit to prevent mortality, the Japanese Society for Abdominal Emergency Medicine in collaboration with four other medical societies launched the Practice Guidelines for Primary Care of Acute Abdomen that were the first English guidelines in the world for the management of acute abdomen. Here we provide the highlights of these guidelines (all CQ and recommendations were shown in supplementary information). Methods: A systematic and comprehensive evaluation of the evidence for epidemiology, diagnosis, differential diagnosis, and primary treatment for acute abdomen was performed to develop the Practice Guidelines for Primary Care of Acute Abdomen 2015. Because many types of pathophysiological events underlie acute abdomen, these guidelines cover the primary care of adult patients with nontraumatic acute abdomen. Results: A total of 108 questions based on 9 subject areas were used to compile 113 recommendations. The subject areas included definition, epidemiology, history taking, physical examination, laboratory test, imaging studies, differential diagnosis, initial treatment, and education. Japanese medical circumstances were considered for grading the recommendations to assure useful information. The two-step methods for the initial management of acute abdomen were proposed. Early use of transfusion and analgesia, particularly intravenous acetaminophen, were recommended. Conclusions: The Practice Guidelines for Primary Care of Acute Abdomen 2015 have been prepared as the first evidence-based guidelines for the management of acute abdomen. We hope that these guidelines contribute to clinical practice and improve the primary care and prognosis of patients with acute abdomen.

Although studies of serum anti-Müllerian hormone (AMH) in predicting ovarian reserve are numerous, many studies utilized patients under age 40. However, the assessment of ovarian reserve is especially critical in older infertile women. This study evaluates the significance of AMH level in patients over age 40 at the time of their first in vitro fertilization (IVF) treatment.Forty-nine women over age 40 were studied. Although serum samples were taken prior to their IVF treatments, the data of serum AMH of patients were not taken into consideration to determine the therapy strategy, including follicle induction in which clomiphene citrate and human menopausal gonadotropin were used.Twelve out of 49 patients achieved a clinical pregnancy (24.4 %). There was a positive correlation between serum AMH levels and the number of oocytes retrieved (P 0.0001). The ROC curve analysis for prediction of poor ovarian response, ≤3 retrieved oocytes, showed that the optimum cut-off level was 1.0 ng/mL for AMH. The lower AMH group (AMH 1.0 ng/ml) showed less chance of undergoing embryo transfer than the higher AMH group (AMH ≥1.0 ng/ml). There was no difference in pregnancy rate between the two groups. Five out of 12 pregnant women exhibited AMH levels of less than 0.4 ng/ml.Assessment of serum AMH concentration in older patients is useful for the prediction of oocytes numbers which may be obtained in IVF. A cut-off level of 1.0 ng/ml AMH can be used to predict poor ovarian response. This cut-off level of AMH of 1.0 ng/ml might be useful to predict whether patients could have an embryo transfer, but had no power to predict achieving pregnancy. On the other hand, our data also showed that patients over age 40 with extreme low levels of AMH still had a chance of pregnancy.

To evaluate the potential impact of adenomyosis on the pregnancy outcomes by retrospectively investigating adenomyosis-complicated pregnancy cases.We performed a retrospective case-control study. Forty-nine singleton pregnancy cases complicated with adenomyosis were included in this study. The controls (n = 245) were singleton pregnant women without adenomyosis and were frequency matched to adenomyosis cases by age, parity, and the need for assisted reproductive technology for this conception. The incidence of obstetrical complications and delivery and neonatal outcomes were examined.Patients in the adenomyosis group were significantly more likely to have a second trimester miscarriage (12.2% versus 1.2%, odds ratio (OR): 11.2, 95% confidence interval (95% CI): 2.2-71.2), preeclampsia (18.3% versus 1.2%, OR: 21.0, 95% CI: 4.8-124.5), placental malposition (14.2% versus 3.2%, OR: 4.9, 95% CI: 1.4-16.3), and preterm delivery (24.4% versus 9.3%, OR: 3.1, 95% CI: 1.2-7.2), compared with the control group.Adenomyosis was associated not only with an increased incidence of preterm delivery, as previously reported, but also with an increased risk of second trimester miscarriage, preeclampsia, and placental malposition, which could lead to poor perinatal outcomes.

Background The relationship between fibroids and infertility remains a critical and unresolved question. During the implantation phase, it is known that uterine peristalsis is dramatically reduced, which is thought to facilitate implantation of the embryo to the endometrium. In the previous study, using a cine MRI mode, we found that less than half of the patients with intramural fibroids exhibited abnormal uterine peristalsis during the mid-luteal phase. In the present study, we further investigated whether myomectomy for patients in the high peristalsis group is a constructive method to normalize uterine peristalsis. Methods The frequency of junctional zone movement was evaluated using a cine MRI mode during the mid-luteal phase. Fifteen infertility patients, who had intramural myomas and exhibited abnormal uterine peristalsis (≥2 times/3 min) in their first MRI, underwent myomectomy and a second MRI. After receiving the second MRI, patients underwent infertility treatment for at least 8 months, and pregnancy rate was evaluated prospectively. Results Among 15 patients, the frequency of uterine peristalsis was normalized (0 or 1 time/3min) in 14 patients. Following myomectomy and second MRI test, 6 of the 15 patients achieved pregnancy (n = 15, pregnancy rate: 40%). Conclusions The presence of uterine fibroids might induce abnormal uterine peristalsis in some patients, leading to infertility, and myomectomy may improve fertility in these patients.

Chlamydia trachomatis (CT) infection in pregnancy can cause maternal disease, adverse pregnancy outcomes, and neonatal disease [1-6]. In general, approximately 80% of CT infected women are asymptomatic or minimally symptomatic. There-fore, screening is the only means to effectively identify infec-tions [2]. In Japan, pregnant women are routinely tested for CT with the Japanese public funds. According to the guide-lines for obstetrical practice in Japan [7], Japanese obstetri-cians must provide a test for the detection of CT for the pre-vention of neonatal CT infection and diagnose urogenital CT infection when CT is detected using polymerase chain reac-tion (PCR), strand displacement amplification, transcription mediated amplification, an enzyme immunoassay, or culture methods in specimens obtained from the uterine cervix (CT nucleic acid detection tests). However, CT antibody detection by IgA tests has been substituted for these methods by some of obstetricians.On October 2014, we requested 2,544 obstetrical facilities that are members of Japan Association of Obstetricians and Gynecologists (JAOG) to provide information of CT screen-ing tests in pregnant women between October 2013 and March 2014. A total of 1,644 (64.6%) of 2,544 obstetrical facilities responded with possible statistical analysis information on a total of 328,788 women, accounting for approximately 65% of all deliveries that occurred in Japan during the study period. Of the 1,644 obstetrical facilities, CT nucleic acid detection PCR tests, CT nucleic acid detection tests except PCR and CT antibody detection tests were performed in 1,221 (74.3%), 408 (24.8%) and 15 (0.9%) facilities, respectively.Table 1 shows the maternal age distribution under the three CT screening tests (CT nucleic acid detection tests with and without PCR and CT antibody detection tests). There were no significant differences in the maternal age distribution among the three CT screening tests groups.Table 2 shows the results of CT screening tests (CT nucle-ic acid detection tests with and without PCR and CT antibody detection tests) of the study population by age. There were no significant differences in the rate of positive CT between the two groups of CT nucleic acid detection screening tests with and without PCR. However, the positive rate by the CT anti-body detection tests was significantly higher than those by the two CT nucleic acid detection tests with and without PCR (P < 0.01 by X

The gonadotropins, follicle‐stimulating hormone (FSH), and luteinizing hormone (LH), are of particular importance in ovarian physiology. However, FSH receptors and LH receptors are not expressed until the secondary follicle stage, indicating that initiation of follicular growth is independent of the gonadotropins. Among many intra‐ovarian growth factors, many studies have shown that bone morphogenetic proteins (BMPs) play pivotal roles in regulating the early phases of follicular growth. The BMP system induces the gonadotropin system by modulating gonadotropin receptors in early‐stage follicles. Interestingly, the BMP system also prevents precocious maturation of the follicle by suppressing luteinization. Signals provoked by the preovulatory LH surge eliminate BMPs, enabling luteinization to progress. Thus, the BMP system and the gonadotropin system seem to cooperate in regulating follicular development, maturation, and luteinization.

Citation Shi J, Yoshino O, Osuga Y, Koga K, Hirota Y, Nose E, Nishii O, Yano T, Taketani Y. Bone morphogenetic protein-2 (BMP-2) increases gene expression of FSH receptor and aromatase and decreases gene expression of LH receptor and stAR in human granulosa Cells. Am J Reprod Immunol 2011; 65: 421–427 Problem A growing body of evidence indicates that bone morphogenetic protein (BMP) cytokines play a key role in female fertility in mammals. BMP-2 is known to be expressed in the ovary of many species. In the present study, we examined the expression and function of BMP-2 in the human ovary. Method of Study BMP-2 mRNA expression in the human ovary was evaluated by in situ hybridization. Human granulosa cells were obtained from in vitro fertilization patients. Human granulosa cells were cultured with recombinant BMP-2 or human chorionic gonadotrophin (HCG), followed by RNA extraction. Results BMP-2 expression was detected in granulosa cells of antral follicles but not of corpus luteum. The in vitro study showed that BMP-2 induced follicular stimulating hormone (FSH) receptor and aromatase expression, while decreasing luteinizing hormone (LH) receptor and steroidogenic acute regulatory protein expression in human granulosa cells. HCG decreased gene expression of BMP-2 and increased BMP and activin membrane-bound inhibitor (BAMBI), an antagonist of BMP-2. Conclusion Expression and disappearance of BMP-2 might contribute to folliculogenesis and luteinization by regulating gonadotropin receptor expression in human granulosa cells. HCG can modulate BMP-2 function by controlling BMP-2 and BAMBI expression.

background: The relationship between fibroids and infertility remains an unsolved question, and management of intramural fibroids is controversial. During the implantation phase, uterine peristalsis is dramatically reduced, which is thought to facilitate embryo implantation. Our aims were to evaluate (i) the occurrence and frequency of uterine peristalsis in infertile women with intramural fibroids and (ii) whether the presence of uterine peristalsis decreases the pregnancy rate. methods: Ninety-five infertile patients with uterine fibroids were examined using magnetic resonance imaging (MRI). Inclusion criteria were as follows: (i) presence of intramural fibroids, excluding submucosal type; (ii) no other significant infertility factors (excluding endometriosis); and (iii) regular menstrual cycles, and MRI performed at the time of implantation (luteal phase day 5–9). The frequency of junctional zone movement was evaluated using cine-mode-display MRI. After MRI, patients underwent infertility treatment for up to 4 months, and the pregnancy rate was evaluated prospectively. results: Fifty-one patients fulfilled the inclusion criteria, and 29 (57%) and 22 (43%) patients were assigned to the low (0 or 1 time/ 3 min) or high frequency (≥2 times/3 min) uterine peristalsis group, respectively. Endometriosis incidence was the same in both groups. Ten out of the 29 patients (34%) in the low-frequency group achieved pregnancy, compared with none of the 22 patients (0%) in the high-frequency group (P , 0.005). Comparing pregnant and non-pregnant cases, 4 of 10 patients (40%) and 9 of 41 patients (22%), respectively, had endometriosis (not significant). conclusions: A higher frequency of uterine peristalsis during the mid-luteal phase might be one of the causes of infertility associated with intramural-type fibroids.

Immunohistochemical staining using human normal ovaries showed that bone morphogenetic protein-6 (BMP-6) was abundantly present in the granulosa cells (GC) of healthy tertiary follicles but not in atretic follicles. An in vitro study showed that BMP-6 induced gene expression of FSH receptor, inhibin/activin beta subunits, and anti-Müllerian hormone (AMH) in human GCs, suggesting that BMP-6 is an important mediator to support healthy follicle growth in the human ovary.

Aim: The association between provider caseload volumes and patient outcomes remains unclear in gynecologic cancer surgery, especially with regard to radical hysterectomies. The present study aims to clarify the effect of provider volumes on short-term postoperative complications after radical hysterectomy for cervical cancer. Methods: We conducted a multicenter study of cervical cancer patients undergoing radical hysterectomy in Japan from October 1, 2006 to February 28, 2007, by collecting medical record-based data on each patient's background, operating time and postoperative complications, as well as hospital/surgeon volumes. Multivariate analyses were performed to examine the effect of hospital/surgeon volumes on operating time and postoperative complications, with adjustments for possible confounders. Results: We collected 407 cases from 84 hospitals around Japan. Higher surgeon volume (≥200 procedures) was associated with shorter operating times (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.16–0.86; P = 0.02) and reduced incidence of postoperative urinary disorders (OR, 0.45; 95% CI, 0.21–0.96; P = 0.04). Hospital volume was not an independent predictor of any of the outcomes. Conclusion: Our results indicate that the rate of postoperative urinary disorders may be a possible benchmark that reflects a surgeon's skill in radical hysterectomy. Thus, high surgeon volume may be a proxy for high quality of care; practice could indeed make perfect in this clinical setting.

Introduction: Endometrial polyps are a common cause of abnormal uterine bleeding. In some cases, premalignant or malignant lesions are identified within polyps in a biopsy or polypectomy specimen. Hysteroscopic polypectomy, a minimal invasive surgical procedure, has the added benefit of accurate pathologic diagnosis based on complete removal of the lesion. Herein we report two cases of successful treatment of stage Ia endometrial carcinoma pathologically-diagnosed by hysteroscopic polypectomy.Case: Case 1: A 49-year-old patient was referred to our hospital for a cervical polypoid lesion protruding from the external cervical os with abnormal vaginal bleeding. Ultrasound and MRI revealed a pedunculated endometrial polyp-like mass in the uterine cavity occupying the cervical canal. The histologic diagnosis after hysteroscopic resection showed an endometrial carcinoma (G2) confined to a small portion of the base of the polypoid lesion, with the prominent portion being a benign polyp. She underwent a semi-radical hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy. Case 2: A 37-year-old patient with a history of secondary infertility was referred to our hospital for selective chromotubation by hysterofiberscopy, in order to clarify the hysterosonographically-diagnosed left tubal obstruction. Hysterofiberscopic examination revealed a tiny polyp without abnormal vessels in the uterine cavity, which showed well-differentiated endometrial adenocarcinoma (G1) by hysteroscopic surgery. The patient was started on continuous oral medroxyprogesterone acetate (600 mg day for 6 months), and subsequently underwent laparoscopically-assisted myomectomy, followed by ovarian stimulation with clomiphene citrate. She gave delivered a male infant by cesarean section at 37 weeks gestation, weighing 2.3 kg.

We investigated whether Toll-like receptor (TLR) 4 is at work in the human endometrium. The expression of TLR4 mRNA in endometrial epithelial cells (EECs) and stromal cells (ESCs) was detected by RT-PCR and in situ hybridization. Western blotting analysis revealed the TLR4 protein expression in both cell populations. Treatment of lipopolysaccharide (LPS), the actions of which are mediated through TLR4, significantly increased IL-8 secretion from cultured ESCs in a dose-dependent fashion. The stimulatory effect of LPS was inhibited by the addition of neutralizing antibodies for TLR4 and CD14. LPS also stimulated nuclear translocation of nuclear factor-kappaB in ESCs, which was also inhibited by these antibodies. On the other hand, LPS did not stimulate IL-8 secretion in cultured EECs. However, LPS stimulated IL-8 secretion from EECs in the presence of soluble CD14. Flow cytometric analysis revealed that CD14 was expressed on the cell surface of ESCs but not EECs. In addition, immunohistochemical analysis showed that CD14 was stained in ESCs but not EECs. Pretreatment of interferon-gamma (IFN-gamma) enhanced LPS-induced IL-8 secretion from ESCs. IFN-gamma increased the expression of TLR4 mRNA. It also increased the amounts of mRNA for CD14, MD2, and MyD88, which are needed for LPS recognition in concert with TLR4. In summary, we demonstrated that both ESCs and EECs express TLR4 and respond to LPS through TLR4. We further showed that EECs, not ESCs, required soluble CD14 for TLR4 activation. Interestingly, IFN-gamma, an antiinfectious cytokine, was found to activate the TLR4 system in ESCs. Altogether, the results imply that the TLR4 system might represent local immunity in the human endometrium with differential modes of TLR4 actions between ESCs and EECs.

Objective: To establish a new method for preoperative bowel preparation that facilitates nursing care and minimizes the patient’s discomfort during the clinical pathway of laparoscopic surgery. Method: A randomized controlled trial was conducted for the following two preparation methods. Twenty cases were assessed with Method 1 and 18 cases with Method 2. Method 1 (the conventional procedure) : oral magnesium citracte is given in the afternoon of the day before surgery, followed by a glycerin enema in the night of the day before surgery and in the morning of the day of surgery. Method 2 (a new procedure) : oral magnesium citrate is given in the afternoon of the day before surgery, followed by oral picosulfate in the night before the day of surgery and a bisacodyl suppository in the morning of the day of surgery. To evaluate the two methods we sent questionnaires to the surgeons (blinded to the method used), nurses, and patients. Results : No statistical difference existed between the two methods in their effectiveness as a preoperative treatment. Facilitation of nursing care was significantly better in Method 2, and patients had considerably reduced discomfort with Method 2. Discussion: Patients who received oral picosulfate and a bisacodyl suppository experienced much less discomfort and nursing care was easier when compared with the conventional method of administering a glycerin enema. Since an enema is disliked by young women and an effect comes out with discomfort very shortly after the administration, the degree of discomfort of patients would have become high. Picosulfate is an oral medicine and thereby the effect comes out mildly. That would be the reason why the degree of discomfort of patients was low. In the nursing care, an enema requires time for preparation and administration, while picosulfate is easy to administer, making the nursing care easier. Therefore, Method 2 was chosen as a preperative bowel treatment for the clinical pathway. Thus, we could establish a new evidence-based method useful for the preperative bowel preparation in the clinical pathway of laparoscopic surgery.

In an animal endometriosis model, the administration of hyaluronic acid (HA) reagent significantly suppressed the formation of endometriotic lesions in both number and weight. This effect was found when HA treatment was conducted at the time of endometrial fragment inoculation.

Two patients, one with high-risk, and one with moderate-risk, highly drug-resistant choriocarcinoma, were treated with multidisciplinary modalities. Treatment effects, as well as disease conditions, were closely evaluated by serial monitoring of urinary or serum human chorionic gonadotropin levels and imaging studies. The patient with high-risk disease was treated with 72 courses of chemotherapy, whole brain irradiation, and 2 thoracotomies over 93 months. She has not yet attained complete remission. The patient with moderate-risk disease was treated with fourth-line chemotherapy consisting of high-dose 5-fluorouracil and actinomycin D, and a subsequent hysterectomy. She has maintained complete remission for more than 2 years. Timely surgical intervention may be a useful strategy for the treatment of highly drug-resistant choriocarcinoma.

Objective To examine the regulation and the function of activin-A in stromal cells derived from endometrioma. Design Molecular studies. Setting University research laboratory. Patient(s) Endometrioma stromal cells (EoSC) were obtained from 28 patients with ovarian endometrioma undergoing laparoscopy. Intervention(s) EoSC were cultured with inflammatory stimuli or recombinant activin-A, followed by RNA extraction. Main Outcome Measure(s) Activin mRNA expression was evaluated by real-time reverse transcription–polymerase chain reaction (RT-PCR), and activin-A concentration of supernatant of cultured EoSC was evaluated by ELISA. Also, the effect of activin-A on EoSC was evaluated with real-time RT-PCR and cell proliferation assay. Result(s) Inflammatory stimuli, interleukin (IL) -1β, and tumor necrosis factor (TNF) -α induced inhibin/activin-βA subunit mRNA and activin-A protein expression in EoSC. Additionally, activin-A enhanced EoSC proliferation and increased the expression of IL-6 and protease-activated receptor (PAR)-2 mRNA. Conclusion(s) An in vitro study revealed that activin-A, which is induced by IL-1β or TNF-α, might promote endometriosis by stimulating IL-6 and PAR-2 mRNA expression and increasing the proliferation of EoSC.

Objective To examine the effect of bone morphogenetic protein 7 (BMP-7) on FSH receptor (FSHR) expression in human granulosa cells. Design Laboratory study using human samples. Setting University hospital. Patient(s) Human granulosa cells were obtained from 60 women undergoing oocyte retrieval for IVF. Intervention(s) Human granulosa cells (GCs) were cultured with recombinant BMP-7, followed by RNA extraction. Main Outcome Measure(s) mRNA levels of GCs were measured by real-time reverse-transcription polymerase chain reaction. Result(s) Bone morphogenetic protein 7 increased FSHR gene expression in human luteinized granulosa cells, whereas it decreased LH receptor gene expression. Bone morphogenetic protein 7 also increased FSH-induced cyclic adenosine monophosphate production in GCs, indicating up-regulation of the cellular response to FSH. Although BMP-7 increased gene expression of activin-βA and -βB in GCs, inhibition of activin function did not affect the BMP-7–induced FSHR gene expression. Conclusion(s) These findings provide new insight into the biologic function of BMP-7 in the human ovary and demonstrate its unique mechanism of regulating FSHR action.

An improved semiquantitative immunoassay method allows human luteinizing hormone (hLH) in urine to be detected from 2.5 to 640 mIU/ml has developed. With this method, the hLH surges in every 3 h urine samples while awake were measured in 8 normal and 12 infertile women. The result was that the urinary hLH surge in infertility was insufficient regardless of the high urinary E2 value. This result may play, at least in part, an etiologic role in infertility.

Background To evaluate the usefulness of transvaginal and transrectal ultrasonography for diagnosis and management of deeply infiltrating rectosigmoid endometriosis. Methods A series of six patients (aged 32-39 years) with rectosigmoid endometriosis underwent transvaginal and transrectal ultrasonography. In three patients undergoing surgical resection of the intestine, the ultrasonographic findings were compared with macroscopic and microscopic findings. In one patient, sequential observations of the lesion using ultrasonography were conducted before and after medical treatment and following childbirth. Results In all cases, the lesion was detected as a hypoechoic irregular-shaped area surrounded by a hyperechoic rim located posterior to the uterus, with size ranging from 18 x 17 to 29 x 28 mm in diameter. The comparison of the ultrasonographical findings with histology revealed that the hypoechoic irregular-shaped area corresponded to a layer of hypertrophic muscularis propria of the lesion, while the hyperechoic rim represented the layer including the mucosa, submucosa and serosa. In one patient, the lesion decreased in size and lost its central hypoechoic area after childbirth in association with pain relief. Conclusions Transvaginal and transrectal ultrasonography provides characteristic appearances for rectosigmoid endometriosis that correlate well with its histological findings. The procedures would be useful in the management of rectosigmoid endometriosis.

In the Department of Obstetrics and Gynecology at our hospital, a team of doctors, pharmacists, nurses, and other medical staff was established to prepare a clinical pathway for laparoscopic cystectomy. Various data on clinical charts including the use of drugs were collected from 57 patients by pharmacists and nurses. Based on the analysis of these data, hospitalization period, method of preoperative bowel preparation, time to initiation of food intake, duration of antibiotic administration, and time and content of pharmaceutical instructions to patients of dosage and administration were determined. Criteria for variances requiring the doctor' s directions were determined for fever, wound pain, and vomiting. The clinical pathway established here allows of not only the efficient and uniform care of patients, but also the active exchange of opinions among members of the medical team. Moreover, most patients who replied to a questionnaire said that they were at ease during hospitalization because they had received detailed information about the clinical pathway including the use of drugs before surgery. Thus, the participation of pharmacists on a medical team that is introducing a clinical pathway is particularly important because the use of drugs and pharmaceutical care are an important part of good patient care.

We have shown that traditional herbal medicine, Shakuyaku-Kanzo-To consisted of Shakuyaku and Kanzo decreased serum testosterone levels in woman and rat. Therefore, paeoniflorin and glycyrrhizin, a main component of Shakuyaku and Kanzo, respectively, and glycyrrhetic acid, a metabolite of glycyrrhizin in vivo, were investigated for the steroid production in the rat ovary on the morning of proestrus. The homogenized tissues of one ovary were incubated in the Dulbecco's modified Eagle medium (pH 7.5) with 100 μg/ml of paeoniflorin, glycyrrhetic acid and glycyrrhizin and the medium only (the control) at 37°C for 270 min. After the centrifugation, the concentrations of Δ4-androstenedione, testosterone and estradiol in the supernatants were determined by RIA. The production of the hormones expressed by [concentration x supernatant volume/ weight of the ovary] was compared to the control. Paeoniflorin, glycyrrhetic acid and glycyrrhizin decreased significantly the testosterone production but did not change that of Δ4-androstenedione and estradiol. Testosterone/ Δ4-androstenedione production ratio was lowered significantly by paeoniflorin, glycyrrhetic acid and glycyrrhizin. Estradiol/testosterone production ratio was increased significantly by glycyrrhetic acid and not changed by paeoniflorin and glycyrrhizin. These results suggest that paeoniflorin, glycyrrhetic acid and glycyrrhizin affect the conversion between Δ4-androstenedione and testosterone to inhibit testosterone synthesis and stimulate the aromatase activity to promote estradiol synthesis by the direct action on the rat proestrous ovary.

Primary pulmonary hypertension (PPH) is an uncommon but serious disease. Most patients with PPH are young women and the disease is more serious and eventful in pregnant women. We have experienced a patient with PPH in pregnancy, who was delivered successfully but died suddenly on the 7th day after the delivery. We report the obstetric course and the clinical management for the delivery of the patient with PPH.

The incidence of the hepatic damage during treatment with danazol (D), indicated by increased serum GOT, GPT and LDH levels, has been shown to be high especially in Japan. Thus, the preventive effect of the traditional herbal medicine, shosaiko-to (SS) was investigated in the administration of D and SS for 16 weeks (D + SS group, N = 9) and the pre-administration of SS for about 4 weeks followed by D and SS for 16 weeks (SS----D + SS group, N = 15). The incidence of serum GOT, GPT and LDH levels of more than normal range during the administration of danazol in the D + SS group was similar to that in the previous study of the administration of D alone. But it was significantly lower in the SS----D + SS group than the D + SS group. The mean levels of serum GOT and GPT were much lower in the SS----D + SS group than the D + SS group throughout the administration of danazol and the difference was significant at 8, 10 and 12 weeks in serum GOT levels and at 4 weeks in serum GPT levels. These results indicate that the pre-administration of SS has great efficacy in the prevention of danazol-induced hepatic damage.

Eight women with normal term pregnancy were i.v. administered 10 mg Metoclopramide (M), dopamine antagonist, before and during labor. Serum prolactin (PRL), TSH, GH and cortisol levels were measured at -30, 0, 30 and 60 minutes after M administration by specific radioimmunoassay. Basal serum PRL levels before labor, 287.5 +/- 28.6 ng/ml (mean +/- S.E.), significantly declined during labor to 237.0 +/- 22.4 and 216.4 +/- 22.9 ng/ml (p less than 0.05 at both) at 0 and 30 minutes before M administration, respectively. The increments in serum PRL at 30 and 60 minutes after M administration during labor (209.5 +/- 33.9 and 120.0 +/- 27.1 ng/ml, respectively) were not significantly different from those before labor (202.1 +/- 48.7 and 89.9 +/- 30.1 ng/ml, respectively), suggesting that the decline in serum PRL levels during labor is not due to the dopaminergic control. Basal serum TSH and GH levels were not significantly changed by labor and M administration either before or during labor. Serum cortisol levels tended to increase during labor, but these changes were not significant. The data suggest that the PRL releases from the pituitary during labor are not controlled by the dopaminergic mechanism.

The effect of the traditional herbal medicine, Shakuyaku-Kanzo-To (SK), which contains Shakuyaku (S) and Kanzo (K) in equal amounts, on serum testosterone levels was investigated in androgen-sterilized rats. They were given orally SK [0, 22.5, 45, 90 and 180 mg/kg body weight (b.w.)] and S or K (0, 11.25, 22.5, 40 and 90 mg/kg b.w.) in 2 ml of water daily for 2 weeks. Dose-dependent decreases in free serum testosterone (T) levels were found in the administration of SK. Total serum T levels in the administration of SK and S decreased in a dose-dependent manner. K decreased totla serum T levels slightly in 11.5 and 22.5 mg/kg doses but showed the dose-dependent increase in much higher doses, the extent of which was much less than that of the decrease in S. Serum estradiol/T (E2/T) ratios were significantly elevated in 45 to 180 mg/kg doses of SK, 90 mg/kg dose of S and 11.25 to 90 mg/kg doses of K. Serum LH and FSH levels were not changes by SK, S and K. Oophorectomized rats were similarly given SK (0, 90 and 180 mg/kg b.w.) and S or K (the half doses of SK). There were no changes in serum T, LH and FSH levels in all given doses. Thus, one of the mechanisms for SK to lower serum T levels in the direct action on the ovary to stimulate the aromatase activity, resulting in decreasing the T secretion and this is the additive effects of S and K.