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Three cases of cervical pregnancy with different clinical parameters were successfully treated with methotrexate. Case 1 was a viable cervical pregnancy, case 2 was a cervical pregnancy after curettage that developed into a cervical hematoma, and case 3 was a cervical pregnancy at an early gestational age. The interval between diagnosis and treatment ranged from 45 to 76 days. The maximum quantitative beta-human chorionic gonadotropin (beta-hCG) levels in cases 1, 2 and 3 were 100,180, 19,093 and 956 mIU/mL, respectively. These patients showed a progressive decline in beta-hCG levels, and ultrasound showed a gradual decrease in the size of the pregnancies. The interval between treatment and beta-hCG resolution ranged from 14 to 59 days. Only in case 2 did side effects occur, including stomatitis and transient elevation of serum transaminase. In view of the risks of standard therapy and patients' desire for fertility, methotrexate treatment may be a therapeutic alternative for cervical pregnancy.

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.

Ovarian preservation before abdominal irradiation may be recommended for young patients with various types of invasive cancer. The most common site for ovarian transposition is just below the iliac crest or posterolateral to the uterus. Here, we demonstrate laparoscopic ovariopexy with an automatic stapling device to transpose the ovaries to an uncommon site, i.e. lower anterolateral abdomen, in a patient with medulloblastoma prior to her receiving irradiation of the craniospinal axis. The anterolateral transposition of the ovary not only kept it away from the irradiated field but allowed it also to be shielded by the uterus. Thus, ovarian function could be well preserved.

Sixty-one laparoscopic presacral neurectomies were performed in Chang Gung Memorial Hospital, Keelung Center over a 1-year period for patients with primary dysmenorrhea who failed to respond to medical management. Eighty-three percent (50) had complete relief of pain, 10% (6) had significant relief, 3.5% (2) had moderate relief, and 3.5% (2) had no relief from their dysmenorrhea at their first menstruation after the procedure. One vascular complication requiring laparotomy occurred. Average total operation time was 24 minutes, and the average hospital stay was 2 days. Six months follow-up was done in 35 patients with complete symptom relief, and all reported continued relief of menstrual pain. The efficacy of laparoscopic presacral neurectomy for the pain relief of primary dysmenorrhea is justified in this report.

Leuprolide acetate (Lupron) belongs to the group of gonadotrophin-releasing hormone agonists (GnRHa). It is used in conjunction with human menopausal gonadotrophin (HMG) and/or follicle stimulating hormone (FSH) for ovarian stimulation in the so-called ultra-short, short or long protocols. In our programme, the long protocol is mainly used, which starts routinely with s.c. administration of Lupron, 1 mg/day, from day 21 of the cycle preceding ovum retrieval. After pituitary desensitization is achieved, gonadotrophin administration is started. However, unexpected, spontaneous pregnancy may occur during the flare-up phase of Lupron administration. We present six pregnancies and four deliveries which have occurred under these circumstances. The mechanisms by which pregnancy may occur and escape from luteolytic, abortifacient and teratogenic effects of prolonged use of GnRHa are discussed, as well as pregnancy outcome.

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.

Objective: To evaluate interrelationships between levels of insulin-like growth factor I (IGF-I), insulin-like growth factor binding protein (IGFBP-I), and ovarian steroids in late preovulatory follicular fluid (FF) after pituitary desensitization with GnRH agonist and controlled ovarian hyperstimulation., Design: Follicular fluid and matched serum were collected during the ovum pick-up. Insulin-like growth factor binding protein I, E2, P, and androstenedione (A) were measured by means of RIA, whereas T was measured by means of fluoroimmunoassay and IGF-I by means of immunoradiometric assay., Setting: University teaching hospital., Participants: Fifty-nine patients underwent 62 ovum pick-ups for IVF., Main Outcome Measures: Levels of IGF-I, IGFBP-I, E2, P4 (representative of follicular maturity), T, and A in FF and the volume of this fluid were determined. Levels of E2 to A (representative of aromatase activity) in FF were examined in relation to the volume of FF., Results: Levels of FF-IGF-I decreased with increasing volume of FF. This observation is unprecedented. In contrast, FF-P increased with increasing volume of FF. The reverse relationships with FF volume between FF-IGF-I and FF-P may not be causal because no correlation was found between concentrations of FF-IGF-I and FF-P. Our findings are consistent with and complementary to those in previous reports. The follicular fluid E2:A ratio, FF-E2, FF-A, FF-T, and FF-IGFBP-I were not found to be correlated with volume of FF., Conclusion: Decreased levels of FF-IGF-I with unaltered levels of FF-IGFBP-I in larger follicles may favor a shift toward diminished action of IGF-I at the time of immediate preovulation. The physiological significance of this shift remains uncertain as it is not reflected in the levels of steroids in FF.

An extremely rare case is reported of small cell carcinoma of the cervix with a fulminating course complicating pregnancy. The primary lesion was first noted in the 27-year old patient at 36 weeks of gestation. Cesarean section followed by radical hysterectomy with bilateral pelvic lymph node dissection was performed. Brain and breast metastases occurred two months after primary surgery, while adjuvant radiotherapy to the pelvis was ongoing. The patient died suddenly of massive tumor emboli in the brain. The microscopic and ultrastructural findings, immunohistochemical studies and flow cytometric analysis are presented.

To investigate the association between low amniotic fluid alpha-fetoprotein (AFP) and trisomy pregnancies, we retrospectively reviewed 26 trisomy pregnancies including 18 fetuses with Down's syndrome and eight with trisomy 18. The amniotic fluid AFP median values of Down's syndrome, trisomy 18, and the study groups were 0.73 MoM, 1.15 MoM, and 0.85 MoM, respectively. There was a significant difference between the mean values of the Down's syndrome-affected fetuses (0.78 +/- 0.29 MoM) and that of the control group (p < 0.001), whereas no such difference was found for that of trisomy 18-affected fetuses (1.16 +/- 0.38 MoM). Only three patients in the study group (3/26, 11.5%) had an amniotic fluid AFP value below 0.5 MoM, including the two cases of Down's syndrome (2/18, 11.1%) and one case of trisomy 18 (1/8, 12.5%). Most of the values for the trisomy pregnancies were within the normal range, thereby precluding the possibility of using this measurement as an alternative to fetal karyotyping as a screening test for Down's syndrome or other trisomy pregnancies.

We present the case of a 29-year-old, pregnant woman who, at 27 weeks' gestation, suffered an acute abdomen with hypovolemic shock that led to intrauterine fetal death in spite of an emergency laparotomy. The final diagnosis was ruptured renal angiomyolipoma, which caused a massive retroperitoneal hemorrhage.

To assess the relationship between alpha-fetoprotein (AFP) concentrations of amniotic fluid and maternal serum from 16 to 18 weeks' gestation, 890 paired samples of maternal serum and amniotic fluid were collected from women with normal singleton pregnancies. The gestational age was determined by ultrasonographic dating before amniocentesis, and the AFP measurements were performed by a single reference laboratory. There was a significant rise in the maternal serum AFP (MSAFP) concentration from 16 to 18 weeks' gestation. Amniotic fluid AFP concentrations significantly declined from 16 to 18 weeks' gestation. This study failed to demonstrate any statistical relationship between the AFP concentration of maternal serum and amniotic fluid (r = 0.031). This finding indicates that amniotic fluid AFP levels cannot be predicted by MSAFP levels between 16 and 18 weeks' gestation. Simple diffusion may not be the only mechanism for the transfer of AFP through the fetal membrane to maternal circulation.

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.

We present a case of alveolar soft part sarcoma of the vagina in an 18-year-old woman. The presenting symptoms were menometrorrhagia and a painless vaginal mass. The tumor was in the vaginal stroma with intact mucosa. Periodic acid-Schiff stain showed positive diastase-resistant crystals in some of the tumor cells. Electron microscopy demonstrated characteristic intracytoplasmic crystals. Formaldehyde-induced fluorescence stain showed no catecholamines, and Grimelius stain showed no argyrophilic granules. Black pigment was found within some tumor cells; it proved to be melanin pigment by Masson-Fontana stain. The tumor mass recurred four months after local excision. Following the second surgical removal, the patient received adjuvant radiotherapy to the whole pelvis, including the vagina. At this writing she was currently alive, without evidence of recurrence, five years after the primary diagnosis.

Background: The role of flow cytometry in predicting prognosis for cervical carcinoma remains unclear., Methods: Flow cytometric analysis was performed on tissues, fixed in formaldehyde solution and embedded in paraffin, from 411 patients with Stage IB or II cervical carcinoma who had been treated with radical abdominal hysterectomy and bilateral pelvic lymphadenectomy., Results: DNA aneuploid-multiploid tumors were found in 37.5%, tetraploid in 4.6%, and diploid-peridiploid in 57.9%. Five-year recurrence-free survival rates of the three groups were 74.3%, 77.8%, and 76.4%, respectively (P > 0.05). DNA aneuploidy and DNA index (DI) of greater than 1.3 were highly correlated to parametria extension. In univariate analysis, pelvic lymph node metastases, stage, parametrial extension, depth of cervical stromal invasion, tumor size, and DI (1.3, 1.4, 1.5 as breakpoint) were significant prognostic factors. DNA ploidy, S-phase fraction, and S-G2M fraction were not significant. In multivariate analysis, DI of greater than 1.3, pelvic node metastases, clinical Stage II, and depth of stromal invasion greater than two-thirds of full cervical thickness were independent and significant variables. The prognostic index (PI), defined by the model, was able to categorize the patients into three distinct risk groups. The 5-year recurrence free survival rates of the low-, intermediate-, and high-risk groups were 89.5%, 73.0%, and 58.9%, respectively (P < 0.0001)., Conclusions: The prognostic value of the DI as a single variable is promising and warrants additional investigation to establish its appropriate use.

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.

Nineteen transvaginal, sono-guided ovarian cyst punctures were performed in 18 patients. These patients, who were high surgical risks, were diagnosed to possess benign ovarian tumors as revealed with sonography. Aspiration curettage of the inner surface of the cyst present during aspiration was also performed to facilitate cytologic diagnosis. The recurrence rate was 11.1%. Sono-guided transvaginal cyst aspiration has been demonstrated here to be the treatment of choice for dealing with an ovarian cyst in patients at high surgical risk.

Eighty-two patients underwent laparoscopic hysterectomies from March 1991 to September 1992. The indications were adenomyosis, myomata uteri, intractable menorrhagia and endometriosis with severe pelvic adhesions. The operations were performed through usage of the techniques of videolaparoscopy, including a combination of Kleppinger bipolar forceps for hemostasis and scissors and/or CO2 laser for lysis of adhesions. Fourteen used the Endo GIA 30 stapler in transecting the infundibulopelvic and/or cardinouterosacral ligament. The mean blood loss was 175 mL, and two patients had intraoperative bladder injuries requiring laparotomy repair, but none of them was related to the utilization of the Endo GIA 30 stapler. Most of the patients were discharged on the second postoperative day. The advantages of laparoscopic hysterectomy are short hospitalization, small blood loss and less postoperative discomfort. Implementation of the Endo GIA 30 stapler could facilitate the procedure.

A 26-year-old nulliparous woman conceived after transfer of three embryos cocultured on a Vero cell monolayer. The ET followed SUZI of epididymal sperm from her husband with congenital absence of vas deferens.

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.

Fecundity rates were measured for 343 patients in 467 cycles of ovulation induction with intrauterine insemination (IUI) from January 1990 to April 1992. Total pregnancy rate per cycle (PR) was 15.6% with a spontaneous abortion (SA) rate of 19.2%, an ectopic pregnancy (EP) rate of 4.1%, a multiple pregnancy (MP) rate of 19.2%, and an ongoing or live-birth (LB) rate of 12.0%. Using gonadotropins as a unique or as an additional stimulatory reagent improved the pregnancy rate of anovulatory patients by more than three-fold over use of clomiphene citrate (CC) alone (33.3% vs 10.7%). In other diagnostic entities, the PRs were higher, but the difference was not statistically significant between these two stimulation protocols (13.9% vs 8.4%; t = 1.70, p > 0.05). Pretreatment sperm motility and the post-treatment total motile sperm count were significantly correlated with the PRs. The same phenomena occurred when the number of follicles > or = 12 mm and the serum estradiol concentrations were taken into account. The highest PR was detected when the endometrial thickness fell between 8 and 13 mm. The spontaneous abortion rate was higher in CC only cycles and when the serum E2 was below 1000 pg/mL on the day human chorionic gonadotropin was administered. A multiple pregnancy could be predicted when a cycle of more than 10 follicles > or = 12 mm was detected (44.4%). The complications of controlled ovarian hyperstimulation with IUI were low and mild in our study, comprising six cases of moderate to severe ovarian hyperstimulation syndrome and three cases of acute pelvic inflammatory disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin-like growth factor-binding proteins (IGFBPs) in sera from non-pregnant and pregnant women, and from the umbilical cord at the time of delivery, were separated by gel filtration chromatography. The binding characteristics of the 150 and 40 kDa binding proteins were examined by Scatchard analysis. In serum from pregnant women, the affinity of the 150 kDa binding proteins (IGFBP-3) decreased as pregnancy progressed, with an apparent increase in the maximum binding capacity. In contrast, the affinity of the 40 kDa binding proteins showed a slight increase. In umbilical cord serum, the binding affinity of both the 150 and 40 kDa binding proteins was similar, whereas the binding capacity was two-fold higher in the 40 kDa than in the 150 kDa group. Both maternal and umbilical cord serum (artery and vein) contained unoccupied IGFBPs. Following acid treatment, there was an increase in binding of 125I-IGF-I to umbilical cord serum but a decrease in that to maternal serum. These changes in the characteristics of the binding proteins in the pregnancy sera are probably due to partial degradation of the 150 kDa binding proteins by proteases. The present data confirm that IGFBP-3 is the main binding protein for IGFs during pregnancy, although its affinity is decreased. In fetal circulation, the 40 kDa binding proteins appear to be the major IGFBP with a high affinity and high capacity.

Forty-six consecutive cases of laparoscopic management of ovarian tumors are reported. In the present study, patients were not included if there was any suspicion of malignancy. Indications for laparoscopic management of ovarian tumors included ovarian cyst (n = 20), endometrioma (n = 22), dermoid cyst (n = 3) and gonadal dysgenesis (n = 1). Postoperative intra-abdominal bleeding occurred in one case in our series and laparotomy was then performed for check-up. The average hospital stay was 2.4 days. The entire tumor was removed through the infraumbilical incision or through the culdotomy. Laparoscopic management of ovarian tumors is a cost-effective and safe procedure.

Objective: To determine if delaying initiation of exogenous gonadotropin administration after pituitary desensitization with gonadotropin-releasing hormone agonist (GnRH-a) is a realistic option to avoid scheduling clinical and laboratory work on weekends/holidays., Design, Patients: A review of 57 in vitro fertilization (IVF) cycles in which, after pituitary desensitization with GnRH-a, initiation of gonadotropin administration were delayed in an attempt to avoid off-hour work. Thirty-eight IVF cohort cycles served as control., Setting: Tertiary medical center., Results: There were no statistically significant differences in ovarian response, dose of gonadotropin required, oocytes and embryos obtained, pregnancy rates, and abortion rates between groups. Eighty-three percent of the delayed cycles had clinical and laboratory work that fell within weekdays., Conclusion: Delaying initiation of exogenous gonadotropin administration after pituitary desensitization had no detrimental effects on IVF outcomes. It may be used to avoid scheduling work on weekends/holidays.

We report the results of a prospective trial using a loop electrosurgical excision procedure (LEEP) on 97 patients with cervical intraepithelial neoplasia. In the LEEP group the mean cutting time and whole procedure time were 6.2 +/- 1.9 seconds and 12.7 +/- 3.5 minutes, respectively. The average blood loss was 3.6 +/- 1.9 mL. In the control group (39 cases) using laser conization, the mean cutting time and whole procedure time were 11.7 +/- 3.5 minutes and 44.9 +/- 8.9 minutes, respectively. The average blood loss in the control group was 11.2 +/- 3.1 mL. The differences between the two groups were statistically significant. During LEEP surgery, four cases had accidental vaginal excision. There were three cases of late cervical bleeding after surgery; the surface of the cervix was smooth, and no adhesion or crypt formation was noted after re-epithelialization. Eight patients became pregnant after the loop excision and no cervical incompetence was noted during antenatal care. After a one-year follow-up period in the colposcopy clinic, there was no recurrence of cervical intraepithelial neoplasia in either group. We advise that among the modalities of treatment for cervical intraepithelial neoplasia, LEEP appears to offer patients several benefits such as less bleeding, precise specimens, local anesthesia, less cost and less discomfort. It is particularly suitable for treating younger women who have not yet completed their families.

A case of adenocarcinoma of the sigmoid colon during pregnancy is reported. The patient presented with anemia and a painless mass over the left abdomen without gastrointestinal discomfort, making this case different from 25 previously reported cases of colon carcinoma above the peritoneal reflection associated with pregnancy.

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.

The incidence of primary cervical choriocarcinoma is extremely low, with only approximately 60 cases reported. We present a case of primary cervical choriocarcinoma, which was originally mis-diagnosed as a cervical pregnancy. After failure of conservative treatment with methotrexate, the patient underwent a hysterectomy, followed by chemotherapy with actinomycin-D. After twenty months of follow-up, the patient is in good condition and her serum beta-hCG levels are normal.

A rare small cell carcinoma with neurosecretory granules arising in an ovarian dermoid cyst with 7 years survival after conservative surgery and adjuvant chemotherapy with cisplatin, adriamycin, and cyclophosphamide is described. Light microscopy showed the typical uniformly small cells with hyperchromic nuclei and scanty basophilic cytoplasm within the mature cystic teratoma. Although none of the immunohistochemical stains were reactive, electron microscopy demonstrated the membrane-bound neurosecretory granules in some tumor cells. The related literature is reviewed and the issues concerning treatment options in this unusual malignancy are discussed.

A case of recurrent small-cell carcinoma of the uterine cervix, initially presenting with cardiac tamponade, is reported. After pericardiotomy, the patient was treated with an alternating combination of chemotherapy, which included cisplatin plus etoposide (CE) and cyclophosphamide, adriamycin plus vincristine (CAV). A partial response, with relief of a cough and diminishing metastatic pulmonary lesions, was noted from serial chest roentgenographs after the initial three cycles of chemotherapy. The patient did not receive any further treatment and the recurrent cough and dyspnea were noted two months later. In spite of the same chemotherapeutic regimen and chest radiotherapy, the patient died nine months after the initial diagnosis of metastasis.

From March to November 1991, 24 patients underwent laparoscopic hysterectomies at Chang Gung Memorial Hospital, Taipei. The indications for hysterectomies included seven patients with adenomyosis, 14 with myoma uteri, one with intractable menorrhagia, and two with endometriosis and severe pelvic adhesions. The surgeries were performed using the techniques of videolaparoscopy, including a combination of Kleppinger bipolar forceps for hemostasis and scissors and/or CO2 laser for lysis of adhesions. The mean blood loss was 210 mL; there was one bladder injury during these procedures. Most of the patients were discharged on the second postoperative day. The advantages of a laparoscopic hysterectomy include a short hospitalization, low blood loss and less postoperative discomfort. Laparoscopic hysterectomy is a cost-effective and safe procedure.

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.

The pregnancy rates for the gamete intra-fallopian transfer (GIFT) and tubal embryo transfer (TET) methods have been shown to be high. The oviductal environment appears to be suitable for fertilization and subsequent cleavage. Many authors have reported that when co-cultured with human ampullary cells, the embryos can develop in vitro as well as in vivo. Thus, significantly more embryos reach the early blastocyst stage, and more successful implantation may be obtained. However, the characteristics of the ampullary cells may change after a series of sub-cultures. In this study, we compared the first and the seventh sub-culture ampullary cell co-cultured systems with a control group. There were significantly more embryos cleaved to blastocysts in these two co-cultured systems than in the control group, but no significant difference between these two co-cultured systems. Detoxification of the medium by co-cultured cells may play an important role in improving embryo quality.

Peripartum cardiomyopathy is a relatively rare complication of pregnancy, characterized by heart failure of obscure etiology during the antepartal or postpartal period. During a 10-year period in our hospital, of 36,882 women who delivered, 6 were diagnosed as having peripartum cardiomyopathy. The incidence in our hospital was estimated as 1:6,147 deliveries. Among these 6 patients, 2 cases with fulminating courses died 1 month after treatment. Two other cases had cardiomyopathy and multiple congestive heart failure and died after 3 years and 6 years. Only one case, whose cardiac size returned to normal within 4 months, completely recovered from this disease. Another survivor with persistent cardiomegaly was followed for 5 years and remained clinically stable. In addition to congestive heart failure, the occurrence of complications such as sepsis, hepatorenal failure, and arrhythmia were the major causes of death. According to the results of our study, return of cardiac chamber size to the normal range indicated a good prognosis. We concluded that the prognosis of peripartum cardiomyopathy depends upon the degree of cardiac dysfunction and the response to therapy.

We present a case of non-mosaic trisomy 20 in amniotic fluid associated with major congenital anomalies. A detailed prenatal ultrasonic examination was performed, and revealed dilatation of the cisterna magna and the fourth ventricle with hypoplasia of the vermis of the cerebellum. Fetal echocardiography showed overriding aorta and ventricular septal defects with pulmonary atresia. However, the karyotype of the lymphocyte in the cord blood was normal female 46, XX. The occurrence of the Dandy-Walker malformation in non-mosaic trisomy 20 has not been reported before, and the clinical significance of this major defect for prenatal diagnosis is discussed.

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.

Twenty-four patients with bulky (greater than 4 cm), advanced (stages IIB-IVA) carcinoma of the uterine cervix were prospectively treated with a concurrent combination of radiotherapy (RT) and chemotherapy (CT). RT consisted of 4400 cGy (22 fractions) to the whole pelvis and a 1400-cGy boost to the parametrium. This was followed by two to three intracavitary brachytherapy courses. CT consisted of one to four course (median, three) of cisplatin (50 mg/m2) on Day 1, vincristine (1 mg/m2) on Day 2, and bleomycin (25 mg/m2) on Days 2-4. CT was started on the first day of external radiation and the scheduled course interval was 21 days. Among the 20 evaluable patients who completed at least one course of chemotherapy and a full course of radiation, 13 (65%) achieved complete response and 5 (25%) had partial response. Fatal complication occurred in 1 patient with stationary disease who died of septic shock due to ruptured pyometra. The other patient with primary stage IVA disease had progressive disease with ascites appearance after two courses of CT and later expired. Transient drug fever occurred in 19 (40.4%) of the 47 bleomycin-containing CT cycles. Grade 2 or 3 hematological toxicities occurred in 16 (30.2%) of a total of 53 CT cycles. Treatment delays of 1 to 7 days occurred in 15 (28.3%) CT cycles. Except for the case of septic shock, all of the other toxicities were generally tolerable and reversible. From this preliminary result we concluded that this particular combination of RT and CT in bulky, advanced cervical carcinoma is effective in enhancing local pelvic tumor control and well tolerated if strict selection of accrued patients is applied. Further investigation to assess its impact on long-term survival is in progress.

Our objective was to evaluate and compare the efficacy and mechanisms of co-culturing mouse embryos with Vero cells in both Dulbecco's modified Eagle's medium/Ham's F12 (DMEM/F12) and human tubal fluid (HTF) culture medium. Two-cell CB6F1 mouse embryos were cultured either in the presence of Vero cells (group A) or in culture medium alone (group B). In DMEM/F12 significantly more morulae developed in group A than in group B on day 3 (91 versus 23%; P less than 0.01). In contrast, the mouse embryos grew rapidly in HTF and significant differences were noted only in later embryonic stages (on day 5; 86% and 50%, P less than 0.01 of group A and B respectively, hatching or hatched). Similar experiments using DF1 and ICR mouse strains also revealed enhanced embryo development in the presence of Vero cells. To determine whether the embryo-enhancing effects of Vero cells were due to the removal of toxins or to the secretion of embryotrophic factors, ICR mouse embryos were cultured in fresh media with cells (group A), without cells (group B) and in cell-free conditions using cell-conditioned media which were obtained in the presence (group C) or absence (group D) of embryos. These results demonstrated that completion of hatching was highest (52%; P less than 0.01) in group A after 6 days in culture. There were no significant differences between groups B, C and D (rates of total hatching 18, 17 and 17%, respectively). It is concluded that Vero cells improve the development of mouse embryos and this is likely to be due to removal of substances inhibitory to development.(ABSTRACT TRUNCATED AT 250 WORDS)

Neoadjuvant chemotherapy consisting of 2-3 courses of cisplatin, vincristine, and bleomycin was used in the primary treatment of 36 consecutive patients with locally advanced early-stage cervical carcinoma [International Federation of Gynecology and Obstetrics (FIGO) stages Ib or IIa; tumor size, greater than or equal to 4 cm]. The effectiveness of the preoperative chemotherapy was evaluated in the surgical specimens. Among the 33 evaluable patients, the overall clinical response rate was 84.8%, which included a complete response in 8 patients (24.2%) and a partial response in 20 subjects (60.6%). No residual tumor was found in the surgical specimens obtained from 2 complete responders. This therapy induced varying degrees of tumor shrinkage and rendered radical surgery feasible in all evaluable cases despite the initial bulky size of the lesions. No significant difference was observed in the response rate according to age and disease stage. Lymph-node metastases were found after chemotherapy in 18.2% (6/33) of the patients. Grade II and III hematological toxicities occurred in 23.3% of the 90 chemotherapy cycles completed. Nausea and vomiting occurred to a mild to moderate degree in 75 (83.3%) cycles. These preliminary results suggest that the administration of induction chemotherapy involving two to three courses of cisplatin, vincristine, and bleomycin prior to surgery is effective in reducing the tumor volume and in providing better circumstances for surgical removal of the early yet bulky cervical tumors and results in tolerable toxicity. This protocol is now undergoing prospective randomized trials to test its impact on long-term survival.

Ectopic pregnancies continue to be a major complication of in vitro fertilization and embryo transfer (IVF-ET). A case of bilateral simultaneous tubal pregnancy after IVF-ET is described. The patient underwent ovum pick-up (OPU) through a laparotomy with concomitant pelvic surgery. Embryo transfer (ET) was performed two days after OPU; this resulted in bilateral tubal pregnancies, diagnosed and treated one month apart. There are several possible causal mechanisms for the increased rate of ectopic pregnancies following IVF-ET. It is important to recognize that care in the transfer technique, with respect to the catheter position and limiting the volume of transfer medium to 20 microL, and an awareness of previous occlusion of the tubal ostia, or of a salpingectomy before IVF-ET, can help to minimize this complication rate. Two important points are the possibility of a simultaneous bilateral tubal pregnancy after IVF-ET, and the necessity of carefully examining both adnexa at the time of surgery for an ectopic pregnancy. Early and accurate diagnosis of a simultaneous bilateral ectopic pregnancy can prevent the necessity of a second operation and reduce maternal morbidity and mortality.

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 1982 to 1984, 189 patients with stage Ib carcinoma of the uterine cervix underwent radical abdominal hysterectomies as primary treatment at Chang Gung Memorial Hospital. Of these patients, six were lost to follow-up. Nineteen of the 183 patients with regular follow-up recurred at intervals of from 9 to 55 months. An assessment of prognostic factors was made by reviewing the chart and pathological findings and correlating them with the patient's present status. Using univariate analysis, bulky tumor size was found to bear the greatest risk of tumor recurrence. Six of the 15 patients (40%) with a diameter of more than 4 cm recurred. The other risk factors included parametrial involvement, histologic type of adenosquamous or adenocarcinoma, lymph node metastasis, poor differentiation, deep cervical stromal invasion, and lymphatic or vascular space invasion. In conclusion, analysis of prognostic factors identified a group of patients at high risk of recurrence and decreased survival, for whom prospective trials of adjunctive treatment should be considered.