Pregnancies following ovum donation in gonadal dysgenesis

A Successful New Case of Twin Pregnancy in a Patient with Swyer Syndrome-An Up-to-Date Review on the Incidence and Outcome of Twin/Multiple Gestations in the Pure 46,XY Gonadal Dysgenesis

Background: The aim of the present study is to report a rare occurrence of a successful twin pregnancy in a woman with pure 46,XY gonadal dysgenesis. Result(s): A patient with Swyer syndrome (pure 46,XY gonadal dysgenesis) presented with a twin pregnancy after in vitro fertilization. Due to unidentified conditions, the patient developed selective intrauterine growth restriction in one of the fetuses. Twins were born at 33 weeks of pregnancy due to the risk of asphyxia. Nonetheless, the patient did not develop gonadal malignancies before the pregnancy and, despite receiving estrogen, remained amenorrheic. Conclusion(s): The aim of this case report is to show the course of twin pregnancy in patients with Swyer syndrome through assisted reproduction. Due to certain disorders in the development of their reproductive organs, such as the less mature uterus, such pregnancies may be associated with an increased risk. The above case report demonstrates the need to systematize methods of pregnancy management in patients with Swyer syndrome, such as: preparation for the pregnancy, assessment of the uterus, medications used, and necessary checkups. Capsule: This case report and review shows clinicians that patients with Swyer syndrome may become pregnant. Twin pregnancies may occur without any major problems through assisted reproduction.

Two successful pregnancies after in vitro fertilisation with oocyte donation in a patient with Swyer syndrome - a case report

Diagnosis of complete XY gonadal dysgenesis exposes the patient to the prospect of infertility and many years of medical treatment in order to avoid the development of diseases associated with this condition. However, sufficiently early diagnosis followed by the implementation of proper therapy improves the prognosis for enabling future pregnancies after IVF through the development of reproductive organs and prevention of health complications of hypoestrogenism such as cardiovascular problems and osteoporosis. This syndrome is very rare and affects 1 in 80,000 women. Due to the high risk of developing a gonadal tumour, prophylactic bilateral gonadectomy is one of the main procedures performed in a relatively brief time after diagnosis. Unfortunately, despite characteristic symptoms like primary amenorrhoea and underdeveloped breasts, the diagnosis is often made quite late. We report the case of a 45-year-old woman who had been diagnosed with Swyer syndrome at the age of 16 years. The patient underwent bilateral gonadectomy one year after the diagnosis due to the associated risk of developing malignancy and was treated since with hormone replacement therapy. At the age of 32 and 34 years, 2 successful IVF procedures were performed with oocyte donations. The pregnancies proceeded without any complications and both were resolved by caesarean section. The healthy sons’ weights were 3600 g and 3700 g, respectively.

Mode of delivery of women with Swyer syndrome in a German case series

OBJECTIVES

For women with Swyer Syndrome, a 46,XY gonadal dysgenesis, full term pregnancies are possible after oocyte donation. According to literature, mode of delivery is almost always by Caesarean section for various reasons. Medical indications are multiple pregnancies and related complications, preeclampsia, an androgynous shaped pelvis and failed induction of labor. Elective Caesarean sections were performed based on maternal request and medical recommendation.

METHODS

Following careful examination and shared decision making, we planned a spontaneous delivery with a patient with Swyer syndrome and tested the different hypotheses regarding anatomical and functional features according to literature. In addition, deliveries of women with Swyer Syndrome were analyzed in a German multicenter case series.

RESULTS

A total of seven women with Swyer syndrome with a total of 10 pregnancies were identified, who later gave birth to twelve live-born children. Seven out of 10 births were performed by elective and non-elective Caesarean section, three births took place vaginally.

CONCLUSIONS

In summary, the risk of Caesarean section delivery has increased, but spontaneous delivery can be attempted in the event of inconspicuous findings.

Mosaic Turner Syndrome Presenting with a 46,XY Karyotype

Although Turner syndrome is most commonly associated with a 45,X genotype, other mosaic genotypes are present in approximately half of all cases. We describe a case of Turner syndrome with a 46,XY genotype by conventional 5-cell karyotype who was subsequently found to have a mosaic genotype of 18% 45,X and 82% 46,XY by 50-cell FISH analysis. Individuals with a mosaic 45,X/46,XY genotype have a variety of phenotypic presentations ranging from male to female which are not correlated with the percentage of mosaicism. Our case represents an extreme example where the genotype is predominately 46,XY and the phenotype typical of Turner syndrome.

Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma

INTRODUCTION

Disorders of Sex Development (DSD) are a wide range of congenital conditions characterized by an incongruence of components involved in sexual differentiation, including gender psychosexual development. The management of such disorders is complex, and one of the most crucial decision is represented by gender assignment. In fact, the primary goal in DSD is to have a gender assignment consistent with the underlying gender identity in order to prevent the distress related to a forthcoming Gender Dysphoria. Historically, gender assignment was based essentially on surgical outcomes, assuming the neutrality of gender identity at birth. This policy has been challenged in the past decade refocusing on the importance of prenatal and postnatal hormonal and genetic influences on psychosexual development.

AIMS

(1) to update the main psychological and medical issues that surround DSD, in particular regarding gender identity and gender assignment; (2) to report specific clinical recommendations according to the different diagnosis.

METHODS

A systematic search of published evidence was performed using Medline (from 1972 to March 2016). Review of the relevant literature and recommendations was based on authors' expertise.

RESULTS

A review of gender identity and assignment in DSD is provided as well as clinical recommendations for the management of individuals with DSD.

CONCLUSIONS

Given the complexity of this management, DSD individuals and their families need to be supported by a specialized multidisciplinary team, which has been universally recognized as the best practice for intersexual conditions. In case of juvenile GD in DSD, the prescription of gonadotropin-releasing hormone analogues, following the World Professional Association for Transgender Health and the Endocrine Society guidelines, should be considered. It should always be taken into account that every DSD person is unique and has to be treated with individualized care. In this perspective, international registries are crucial to improve the understanding of these challenging conditions and clinical practice, in providing a better prediction of gender identity.

Rare successful pregnancy in a patient with Swyer Syndrome

Objective

To report a rare successful pregnancy after fertility treatment in a patient with Swyer syndrome.

Design

Case report.

Setting

Herts & Essex Fertility Centre, Cheshunt, UK.

Patients

A 36-year-old patient with 46, XY gonadal dysgenesis. 31 year old husband with normal sperm analysis.

Interventions

Chromosomal analysis, Saline infusion sonography, Pipelle endometrial scratch, ICSI using donor eggs, Embryo Transfer, and Caesarean delivery.

Main Outcome Measures

Successful pregnancy and live birth.

Results

Successful treatment with donor eggs, pregnancy, and delivery.

Conclusions

A patient with 46, XY gonadal dysgenesis in a specially tailored fertility program, can maintain a normal pregnancy and delivery.

Natural Micronized Progesterone Sustained Release (SR) and Luteal Phase: Role Redefined!!

Role of progesterone in reproductive medicine is evolving with its suggested clinical role for the hormonal and nonhormonal actions in reproductive medicine. The main function of progesterone is to induce 'secretory' changes in endometrium that is further complimented by its immunomodulatory and anti-inflammatory actions. It positively modulates PIBF, NK cells and HOXA 10 genes for better implantation. MHRA recommends Serum Progesterone levels ≥14ng/ml in the mid-luteal phase for supporting pregnancy adequately. Oral Natural Micronized Progesterone SR formulation represents a therapeutic advance in this direction offering 'therapeutic compliance' with oral formulation while avoiding the local side effects related to long-term patient compliance in reproductive disorders. The formulation offers round the clock efficiency and efficacy with single dose administration thereby improving patient convenience and compliance. This formulation has been marketed globally since 1986 utilizing the well validated drug delivery system involving Methylcellulose base. The clinical utility of this formulation is further suggested especially in various conditions related with luteal phase insufficiency and Bad obstetric history (BOH) or luteal phase support in ART. The level of evidence has been quite robust with several clinical studies including Prescription Event Monitoring and Investigator initiated studies supporting the clinical role of oral NMP SR formulation especially in 'Real world' clinic settings for Luteal phase insufficiency that may be physiological or iatrogenic.

Evaluation and management of disorders of sex development: multidisciplinary approach to a complex diagnosis

Various disorders of sex development (DSD) result in abnormal development of genitalia, which may be recognized at prenatal ultrasonography, immediately after birth, or later in life. Current methods for diagnosing DSD include a thorough physical examination, laboratory tests to determine hormone levels and identify chromosomal abnormalities, and radiologic imaging of the genitourinary tract and adjacent organs. Because of the complex nature of DSD, the participation of a multidisciplinary team is required to address the patient's medical needs as well as any psychosocial issues that the patient or the family may encounter after the diagnosis. The first step in the management of DSD is sex assignment, which is based on factors such as the genotype; the presence, location, and appearance of reproductive organs; the potential for fertility; and the cultural background and beliefs of the patient's family. The primary goal of sex assignment is to achieve the greatest possible consistency between the patient's assigned sex and his or her gender identity. Once the sex is assigned, the next step in management might be surgery, hormone therapy, or no intervention at all. Patients with ovotesticular DSD and gonadal dysgenesis may require a gonadectomy, followed by reconstructive surgery. Some patients may need hormone replacement therapy during puberty. An understanding of the immediacy of families' need for sex assignment and clinicians' need for reliable diagnostic imaging results will help radiologists participate effectively in the prenatal and postnatal assessment of patients with DSD.

Assisted reproductive technology and pregnancy-related hypertensive complications: a systematic review

Hypertensive complications in pregnancy are the leading cause of maternal morbidity, at least in the developed countries. In recent years, infertility issues are managed with ever growing therapeutic options namely assisted reproductive technologies (ART), which improve the ratio of successful induction of pregnancy. It is still debated whether various ART modalities are associated with adverse pregnancy outcomes, including hypertensive complications, particularly with higher incidence of preeclampsia. The main source of controversy stems from the diversity of effect modifiers modulating the association between ART-oriented pregnancy and hypertensive disorders. Indeed, women undergoing an ART procedure are affected by diverse causes of infertility, are frequently characterized by different genetic patterns with respect to their artificially conceived embryo and experienced multiple gestations. In order to investigate whether ART modalities are associated with increased incidence of hypertensive complications in pregnancy, we reviewed all published studies carried out before the end of 2010 and identified in the PubMed database. Among the 47 studies finally selected and by acknowledging the potential of shortcomings related to the different study design and populations, the overall evidence suggests that ART-oriented pregnancies-especially the in-vitro fertilization techniques-are accompanied by increased risk for gestational hypertension and preeclampsia as compared with non-ART pregnancies, even after adjustment for confounders. Multiple gestations, advanced age and underlying polycystic ovary syndrome resulted in constant confounders of the questioned association. Reducing multiple gestations by implementing single embryo techniques might be the therapeutic limiting step to lower the rate of hypertensive complications in assisted pregnancies.

A model of delivering multi-disciplinary care to people with 46 XY DSD

In 2006, a consensus statement was jointly produced by the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society of Paediatric Endocrinology (ESPE) concerning the management of disorders of sex development (DSD) [1]. A recommendation provided by this consensus was that evaluation and long-term care for people affected by DSD should be performed at medical centers with multi-disciplinary teams experienced in such conditions. Here we provide our team's interpretation of the 2006 consensus statement recommendations and its translation into a clinical protocol for individuals affected by 46 XY DSD with either female, or ambiguous, genitalia at birth. Options for medical and surgical management, transitioning of care, and the use of mental health services and peer support groups are discussed. Finally, we provide preliminary data to support the application of our model for delivering multi-disciplinary care and support to patients and their families.

Successful pregnancy in a Swyer syndrome patient with preexisting hypertension

OBJECTIVE

To report a case of a successful pregnancy and delivery of a patient with 46,XY pure gonadal dysgenesis (Swyer syndrome) and preexisting chronic hypertension who underwent in vitro fertilization (IVF) and embryo transfer (ET).

DESIGN

Case report and review of the literature.

SETTING

2nd Department of Obstetrics and Gynecology, University of Athens, Medical School, "Aretaieion" Hospital. Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery.

PATIENT(S)

A 35-year-old woman with Swyer syndrome and chronic idiopathic hypertension.

INTERVENTION(S)

Karyotype analysis due to primary amenorrhea; gonadectomy, hormone therapy, investigation of hypertension, IVF using donor oocytes, embryo transfer and caesarean delivery for fetal distress.

MAIN OUTCOME MEASURE(S)

Successful pregnancy and live birth.

RESULT(S)

We present a rare case of a successful pregnancy of a patient with Swyer syndrome accompanied by idiopathic chronic hypertension.

CONCLUSION(S)

A woman with Swyer syndrome, hypoplastic uterus, and chronic hypertension delivered a healthy newborn.

Pregnancy in patient with Swyer syndrome

OBJECTIVE

To report a case of successful pregnancy and delivery after IVF and ET in a patient with Swyer syndrome.

DESIGN

Case report.

SETTING

Unit of Assisted Reproduction, Gynecology and Obstetrics Institute, University of Belgrade.

PATIENT(S)

A 30-year-old patient with 46,XY gonadal dysgenesis.

INTERVENTION(S)

Chromosomal analysis, diagnostic laparoscopy, IVF using donor oocytes, ET, and cesarean delivery.

MAIN OUTCOME MEASURE(S)

Successful pregnancy and live birth.

RESULT(S)

Successful treatment, pregnancy, and delivery.

CONCLUSION(S)

A patient with 46,XY gonadal dysgenesis in a donor oocyte program, can maintain a normal pregnancy and delivery.

Long-term health issues of women with XY karyotype

46XY women is a label that gathers together a number of different conditions for which the natural history in to adult life is still only partially known. A common feature is the difficulty that many women encounter when approaching clinicians. In this review we assemble medical, surgical and psychological literature pertaining adult 46XY women together with our experience gained from an adult DSD clinic. There is increasing awareness for the need for multidisciplinary team involving endocrinologist, gynaecology, nurse specialist and particularly clinical psychologists. Management of adult women with a 46XY karyotype includes several aspects: revising the diagnosis in those with previously incomplete workup; exploring issues of disclosure of details of the diagnosis. Surgery needs to be discussed when the gonads are still in situ and when partial virilisation of genitalia have occurred. To maintain secondary sexual characteristics, for general well being and for bone health, most women require sex steroid replacement continuously until the approximately age of 50 and it is important that the treatment is tailored on individual basis. Women should have access to advice about fertility options involving egg donation and surrogacy.

A unique case of trichorionic quadruplet pregnancy after oocyte donation in a patient with Turner's syndrome

A 26-year old patient with a mosaic (45X/46XX) Turner's syndrome and secondary amenorrhea since the age of 19, was referred to the IVF unit for participation in oocyte donation program. After a complete work up including meticulous cardiological assessment, she had endometrial preparation with a high dose hormonal regimen, and transfer of three embryos derived from donated oocytes. An ongoing trichorionic quadruplet pregnancy was confirmed on ultrasound. The couple was offered fetal reduction to twins at 12 gestational weeks after consultation stressing the risks of a quadruplet pregnancy in general and especially in a patient with Turner's syndrome. No pregnancy or maternal complications were encountered and the patient delivered two healthy babies by lower segment cesarean section after spontaneous rupture of membranes at 36 gestational weeks.

[Oocyte donation in patients with Turner syndrome: A high-risk pregnancy]

Turner's syndrome is characterized by an ovarian failure, which occurs in most cases before puberty and leads to infertility. In vitro fertilization with oocyte donation has dramatically transformed the prognosis of infertility of these women. However, in the same time, it has become obvious that pregnancies in Turner's syndrome are at very high risk of possible sudden death because of a specific risk for cardiovascular complications involving aortic root dissection. We report the case of a serious cardiac failure occurred during a twin pregnancy obtained by oocyte donation in a 39-year-old patient with Turner's syndrome. Pregnancy outcome was hopefully favourable thanks to a foetal extraction at 27 weeks of amenorrhoea. If the most reported cases of maternal deaths in patients with Turner's syndrome are associated with an aortic root dissection, our observation is characterized by a full normal cardiologic assessment before the pregnancy and by the absence of aortic root dilatation during pregnancy. This case also illustrates the very high risk of pregnancy in women with Turner's syndrome and the importance of a multidisciplinary care by professionals informed and been used to this obstetric practice.

[Procreation in Turner's syndrome: which recommendations before, during and after pregnancy?]

Turner's Syndrome (TS) is characterized by an ovarian failure which occurs in most cases before puberty and leads to infertility. In less than 10% of women with TS, puberty may occur and spontaneous pregnancies are possible with a high risk of fetal loss, chromosomal and congenital abnormalities. Fertile women with TS should therefore be counselled with regard to these increased risks and be offered prenatal diagnosis testing. For all the other women with TS, in vitro fertilization with oocyte donation (OD) has dramatically transformed the prognosis of infertility. However, in the same time, it has become obvious that pregnancies in TS either spontaneous or obtained after oocyte donation are at very high risk of possible sudden death. Miscarriages are very frequent probably linked to uterine abnormalities. The most specific risks lie in cardiovascular complications involving aortic root dissection, severe hypertension (HTA) or ventricular insufficiency. In fact pregnancies in TS women cumulate the risk of congenital heart defects and HTA associated to TS, the risk of preeclampsia associated to oocyte donation and the increased cardiac work necessary for pregnancy. It is therefore absolutely necessary for all women with TS to undergo a full cardiological assessment before seeking to become pregnant including echocardiography, thoracic magnetic resonance imaging (MRI) to verify aortic root, cardiac valves and left ventricular function, hypertension monitoring and treatment. Single embryo transfer must definitively be considered. Cardiovascular surveillance during pregnancy has to be enhanced especially at the third trimester and during the peripartum period, most women requiring caesarean section for delivery because of cephalopelvic disproportion and/or aortic root dilatation risk.

A case report of successful pregnancy in a patient with pure 46,XY gonadal dysgenesis

OBJECTIVE

To report a successful pregnancy in a patient with pure 46,XY gonadal dysgenesis.

DESIGN

Case report.

SETTING

Academic reproductive endocrinology and infertility unit.

PATIENT(S)

A patient with pure 46,XY gonadal dysgenesis and a desire to become pregnant.

INTERVENTION(S)

Laparoscopic gonadectomy, in vitro fertilization using donor oocytes, transfer of cryopreserved blastocysts, and cesarean delivery.

MAIN OUTCOME MEASURE(S)

Successful pregnancy and live birth.

RESULT(S)

Successful pregnancy and delivery of a healthy infant following in vitro fertilization using donor oocytes and embryo transfer.

CONCLUSION(S)

With the use of donor oocytes, patients with pure 46,XY gonadal dysgenesis can anticipate successful pregnancy.

[Current practices of oocyte donation in France and Europe]

This review aims to evaluate, in France, oocyte donation, an assisted reproductive technique (ART), for which 25 years of experience have shown its efficacy for the palliative treatment of infertility caused by ovarian exocrine failure. Its indications have since been expanded to cover certain genetic diseases and document failures of other ART attempts. Oocyte donation is performed within the framework of French legislation - bioethics laws 94-653 and 94-654 of 29 July 1994, and the revised bioethics law 2004-800 of 6 August 2004. Its main fundamental principles are: voluntary, free, anonymous donation, for which regulated confidentiality is assured and now - judicial decree 2004-606 of 24 June 2004 - and the synchronization of donor-recipient cycles with fresh embryo transfer in accordance with established safety procedures. According to the 2004 results of the French Group for the Study of Oocyte Donation (GEDO) for French centers actively involved in ART, the chance of pregnancy was increased to 43.4% for synchronized cycles with fresh embryo transfers versus 18.7% for deferred cycles with frozen-thawed embryos (P<0.01). In addition, follow-up studies reported the excellent family relationships and physical and psychological development of these children. The major difficulties encountered in the daily practice of oocyte donation concern the recruitment and management of donors, but also, and above all, the lack of optimal means to exercise this medical specialty, due to the lack of recognition of the organizational duties incurred, which are the cornerstone of the character-specific functioning of this type of ART. In comparison, we foresee that the discrepancies of this ART practice in Europe, with it differential facets, will lead to medical nomadism for those couples financially able to do so, when national conditions of access fail because of prohibitions but also as a consequence of insufficient means to perform the inherent tasks. Today, it seems essential to provide information on the particularity and practice of oocyte donation required for the comprehension of its obligations for the different players with the aim of obtaining the means necessary for the perpetuation of its practice.

Successful pregnancy in a gonadectomized woman with 46,XY gonadal dysgenesis and gonadoblastoma

OBJECTIVE

To present a case of successful pregnancy after conservative bilateral gonadectomy without adjuvant chemotherapy and radiotherapy in a 46,XY gonadal dysgenetic woman with gonadoblastoma and malignant germ cell tumor.

DESIGN

Case report.

SETTING

Infertility center in university hospital.

PATIENT(S)

An 18-year-old female with 46,XY karyotype underwent bilateral gonadectomy, and the pathology revealed gonadoblastoma with malignant mixed germ cell tumor.

INTERVENTION(S)

Chromosomal analysis, bilateral gonadectomy, donor oocyte, and IVF program.

MAIN OUTCOME MEASURE(S)

Tumor markers and pregnancy result.

RESULT(S)

The patient was free from tumor recurrence after 13 years' follow-up. A successful twin pregnancy was achieved after oocyte donation and IVF.

CONCLUSION(S)

Gonadectomy without adjuvant therapies could be done in 46,XY gonadal dysgenetic women with gonadoblastoma in view of preservation of future fertility.

Don d’ovocytes en France et bilan national (GEDO). Dispositions différentielles européennes

Oocyte donation (OD), a technique successfully used in Assisted reproductive techniques (ART), has been effective for 20 years as the palliative treatment of certain exocrine ovarian failures. Its indications have also been extended to cover some genetic diseases and documented occult ovarian insufficiency. In France, after an extensive judicial and ethical deliberation, OD was deemed legal and its practice was proscribed in the Bioethics Laws 94-653 and 94-654 of 29 July 1994. Its essential underlying principles are: voluntary, free, anonymous and confidential OD; according to a French decree to meet safety concerns, OD-derived embryos must be quarantined for six months. In vitro fertilization (IVF) programs using donated oocytes are conducted in authorized centers under the responsibility of physicians authorized to retrieve and manipulate donated oocytes. The managers of these programs are the system's keystone, as their role includes, among other, the verification of indications, legal documents, public health safety, anonymous pairing of donor and recipient, and the collection of outcome data. At present, depending of the year, French programs have achieved 17-22% clinical pregnancy rates from transferred OD-derived frozen-thawed embryos, and follow-up studies reported excellent results concerning family relationships, and the physical and psychological development of the children. However, difficulties encountered in the daily practice of OD have led concerned physicians to form the Study group for OD (GEDO) to explore different topics with the aim of improving the overall management of this form of ART. We discussed these points herein, in comparison with the approaches of other European countries.

[Turner's syndrome and oocyte donation]

This paper reviews literature about oocyte donation for patients with Turner's syndrome and reports the experience of our center. Before contemplating pregnancy, it is essential to perform a careful evaluation of the cardiovascular system, the renal system, the thyroid status and the glucose tolerance. Different studies have reported a suboptimal response of the endometrium of women with Turner's syndrome to oestrogen therapy, and suggested that higher doses of estrogens may be necessary to achieve appropriate endometrial preparation. Pregnancy rate per transfer following oocyte donation is around 30% for patients with Turner's syndrome, comparable to the one observed for patients with other conditions requiring oocyte donation. Miscarriage rate is however higher (40-50%) after oocyte donation in Turner's syndrome, and could be related to the presence of a hypoplastic uterus along with hypovascularization. During pregnancy, cardiovascular complications are potentially the most severe, such as the exacerbation of a preexisting hypertension and the dissection of aortic aneurysms. There is a high rate of Caesarean section among Turner's syndrome patients, the main reason being fetopelvic disproportion. Regarding the increased obstetrical risks in Turner's syndrome patients, the selective transfer of one embryo should ideally be performed in order to avoid additional risks associated with multiple pregnancies. In our center, 9 patients with a Turner's syndrome had 15 cycles of oocyte donation. Five pregnancies were obtained among which three were evolutive. The outcome of oocyte donation cycles were comparable for patients with a Turner's syndrome and for patients with other indications of oocyte donation.

Successful pregnancy in a patient with a 46,XY karyotype

OBJECTIVE

To report a case of successful pregnancy in a patient with 46,XY karyotype with primary ovarian failure.

DESIGN

Case report.

SETTING

Fertility Research Center, G.G. Hospital, Chennai, Tamil Nadu, India.

PATIENT(S)

A 27-year-old woman with hypoplastic uterus, normal fallopian tubes on both sides, and gonadal dysgenesis.

INTERVENTION(S)

Chromosomal analysis, diagnostic laparoscopy, donor oocyte program, gamete intrafallopian transfer, and gonadectomy.

MAIN OUTCOME MEASURE(S)

Response to hormone replacement therapy and the probability of achieving a pregnancy by a tubal procedure.

RESULT(S)

Treatment was successful, and the patient delivered a live baby.

CONCLUSION(S)

A hypoplastic uterus of patients with the 46,XY karyotype can be stimulated by the use of cyclical steroid therapy to accommodate pregnancy and facilitate tubal procedures in patients with normal fallopian tubes.

Gonadoblastoma and dysgerminoma associated with XY gonadal dysgenesis in an adolescent with chronic renal failure: a case of Frasier syndrome

STUDY OBJECTIVES

To report a rare reason for primary amenorrhea, a Frasier syndrome, XY gonadal dysgenesis associated with renal failure with eventual development of gonadoblastoma. To study immunohistochemical analysis of gonadoblastoma and dysgerminoma. To analyze the possibility of androgen receptor mutation in this rare syndrome.

METHODS

We report a case of a 16-yr-old female with this syndrome. She underwent a laparoscopic bilateral gonadectomy and salpingectomy. A histopathological examination revealed gonadoblastoma with focal malignant dysgerminoma in the left dysgenetic gonad and an immunohistochemical of these fairly rare, malignant tumors. An androgen receptor was coded. Analysis was done.

RESULTS

Immunohistochemical analysis showed that inhibin was strongly positive in gonadoblastoma but negative in dysgerminoma. No mutations of the androgen receptor gene were found.

CONCLUSIONS

Inhibin positivity in gonadal stroma and in gonadoblastoma may indicate hormonal activity causing advanced puberty in patients with XY gonadal dysgenesis.

Laparoscopic removal of gonads in a Turner's syndrome mosaic female patient with isodicentric Y chromosome

We report a case of laparoscopic adnexectomy in a prepubertal girl with an isodicentric Y chromosome and mosaic Turner's syndrome. This is the second reported case of laparoscopic adnexectomy in such patients.

Oocyte donation: clinical and practical aspects

Oocyte donation is an effective treatment modality for women lacking functioning ovaries, but also for women in whom repetitive in-vitro fertilization (IVF) cycles did not result in the development of adequate number of oocytes as well as for those at risk of transmitting genetic diseases. In women with ovarian failure, artificial menstrual cycles are required in order to produce endometrial growth and differentiation similar to that in women with normal ovarian function. Synchronization of donor's and recipient's cycles is mandatory, since the window of implantation is rather limited. The excellent results of oocyte donation treatment confirm that this assisted reproduction technique can provide a novel approach for the treatment of infertility in these groups of patients. Nevertheless, pregnancies in women of advanced reproductive age are associated with significantly more obstetrical complications and higher perinatal morbidity and mortality rates. Furthermore, aging parents have considerably higher chances to develop serious or life-threatening diseases. Thus, careful medical screening and extensive counselling is mandatory, taking into account the psychosocial ramifications of the procedure and, especially, the best interest of the child-to-be.

Comparison of the pharmacokinetics of crinone 8% administered vaginally versus Prometrium administered orally in postmenopausal women(3)

OBJECTIVE

Compare the pharmacokinetics of vaginal progesterone gel (Crinone 8%, 90 mg) with that of oral progesterone (Prometrium, 100 mg).

DESIGN

Open-label, randomized, parallel-group protocol.

SETTING

Outpatient clinic.

PATIENT(S)

Twelve healthy postmenopausal women.

INTERVENTION(S)

Six subjects each were randomized to receive progesterone, which was administered either as 90 mg of progesterone gel (Crinone 8%) given vaginally or 100 mg progesterone in a capsule (Prometrium) given orally.

MAIN OUTCOME MEASUREMENT(S)

Serum progesterone levels were measured by both radioimmunoassay (RIA) and liquid chromatography-mass spectrometry (LC-MS).

RESULT(S)

Progesterone given vaginally resulted in greater bioavailability with less relative variability in absorption than oral progesterone (mean AUC(0-24) = 1.48 +/- 0.16 ng. h/mL per milligram vs. 0.035 +/- 0.0052 ng. h/mL per milligram). Mean C(max) for oral progesterone was much lower than that of vaginal progesterone (i.e., 2.20 +/- 3. 06 ng/mL vs. 10.51 +/- 0.46 ng/mL). Mean T(max) occurred earlier for oral progesterone than for Crinone (1.00 +/- 0.41 hours vs. 7.67 +/- 3.67 hours). Radioimmunoassay is inappropriate for determining serum progesterone levels after oral administration, because it provided erroneously high values that were approximately eightfold higher than those obtained with LC-MS.

CONCLUSION(S)

Crinone (progesterone gel) given vaginally results in greater bioavailability with less relative variability than oral progesterone, thus providing more reliable delivery of progesterone, compared with oral progesterone. Measuring circulating progesterone with use of direct RIA is not appropriate after oral progesterone administration.

Subsequent successful pregnancy and delivery after intracytoplasmic sperm injection in a patient with XY gonadal dysgenesisms

Report of a rare case of subsequent twin delivery after intracytoplasmic sperm injection (ICSI) into donated oocytes in a 30-year-old woman with a diagnosis of XY dysgenesis, who underwent a gonadectomy at the age of 13 years. Her husband suffers from severe oligo-astheno-terato-spermia.

The influence of donated gametes on the incidence of hypertensive disorders of pregnancy

Pregnancies achieved from oocyte, sperm or embryo donation are unique, since they have resulted from donor gametes that are immunologically foreign to the mother. Thus, studying the obstetric outcome of such pregnancies may shed some light on the pathophysiology of preeclampsia, particularly in women conceiving with donated embryos, since the entire fetal genome is allogenic in these pregnancies. In this retrospective cohort study, a total of 144 women were studied. Of these, 72 were infertility patients who had conceived as a result of sperm, ovum or embryo donation and the other 72 women were age- and parity-matched control patients who became pregnant with their own gametes, either spontaneously, or following intrauterine insemination with their partner's spermatozoa. Study patients were divided into three groups depending on the origin of the donated gametes. Group 1 consisted of pregnancies achieved by intrauterine insemination with washed donor spermatozoa (n = 33). Group 2 included women who conceived using donated oocytes (n = 27) and group 3 consisted of women who conceived as a result of embryo donation (n = 12). The incidence of pregnancy-induced hypertension in the donated gametes study group was 12.5% (9/72) compared with 2.8% (2/72) in the control group. In addition, pre-eclampsia was diagnosed in 18.1% (13/72) of the donated gametes study group compared to 1.4% (1/72) in the age- and parity-matched controls. The increased incidence of gestational hypertension in pregnancies resulting from donated gametes gives evidence for a maternal genetic component, with an equally strong fetal influence, in the complicated aetiology of gestational hypertension, and pre-eclampsia in particular.

Laparoscopic gonadectomy in male pseudohermaphrodites

OBJECTIVE

To study patients of male pseudohermaphroditism and establish the laparoscopic approach for gonadectomy in these cases.

STUDY DESIGN

Seven phenotypic females with XY karyotype were evaluated through a diagnostic protocol which included clinical, cytogenetic, hormonal, endoscopic and histologic evaluation. The gonads were then removed by laparoscopic surgery.

RESULTS

The seven patients included three patients of pure gonadal dysgenesis, two patients of testicular feminization and one patient each of mixed gonadal dysgenesis and dysgenetic male pseudohermaphroditism. Two of the seven patients (28.57%) had gonadal neoplasias on histopathology-one dysgerminoma and one occult seminoma. In all of these patients, removal of the gonads was accomplished laparoscopically. No complications occurred during any of the surgeries.

CONCLUSION

Due to the reduced morbidity, shorter hospital stay and safety, laparoscopic gonadectomy can be considered the treatment of choice for the removal of gonads in male pseudohermaphrodites in the hands of experienced laparoscopic surgeons.

Laparoscopic gonadectomy in two patients with gonadal dysgenesis

Individuals with androgen insensitivity syndrome have a high risk (20-30%) of developing malignancy in their gonads. Accordingly, bilateral gonadectomy is recommended. In a 17-year-old woman with Swyer syndrome gonads were located as streaks above the pelvic brim. In a 13-year-old with Morris syndrome they were located within the inguinal canals. Bilateral laparoscopic gonadectomy was performed under general anesthesia in both patients without complications. We suggest that in phenotypic females with 46,XY karyotype, the procedure may be performed safely, even with gonads located in inguinal canals.

Obstetric outcome in 232 ovum donation pregnancies

OBJECTIVE

To study the obstetric outcome of ovum donation pregnancies.

DESIGN

A retrospective analysis of 232 ovum donation pregnancies in the six years from 1988 to 1993.

SETTING

Infertility clinic in a private hospital.

PARTICIPANTS

All ovum donation recipients that achieved pregnancy in the clinic during the stated time period.

MAIN OUTCOME MEASURES

Percentages of live birth and miscarriages and ectopic pregnancies; number of sacs identified in the uterus at early (four weeks after transfer) and later scans; incidence of antepartum and postpartum haemorrhage; incidence of pregnancy-induced hypertension; incidence of preterm, low birthweight and small-for-gestational age babies; and incidence of operative deliveries.

RESULTS

Of 232 pregnancies, 151 babies were born (live birth rate of 20%); and 81 were lost (57 before eight weeks, 17 after eight weeks and seven ectopic pregnancies). In nine cases there were no intrauterine sacs at the early scan (two 'chemical pregnancies' and seven ectopic pregnancies). In 169 cases there was initially one intrauterine sac, ending with 102 singleton deliveries (60%); in 47 cases there were initially two intrauterine sacs, ending with 11 singleton deliveries (23%) and 32 twin deliveries (68%); in the seven cases where three sacs were identified initially, there were no singleton deliveries, three twin deliveries (one selective fetal reduction) and three triplet deliveries. Women with premature ovarian failures had a significantly higher pregnancy rate compared with those with functioning ovaries (P < 0.02). However, in the former group, the miscarriage rate was also significantly higher (P < 0.03) so that the number of term births was similar. The incidence of vaginal bleeding was 12% in the first trimester, 1.5% in the second trimester, and 2% in the third trimester. The incidence of postpartum haemorrhage was 12%. Thirty-two women had pregnancy-induced hypertension (23% of all deliveries). This occurred in 22/105 singletons (21%), 7/32 twins (22%) and in all three (100%) of the triplets. In the singleton group 13% of infants were preterm, 18% had a birthweight < 2.5 kg and 15% were < 3rd centile for birthweight at delivery (small-for-gestational age). Ovarian function was found to be the only factor that significantly influenced the incidence of small-for-gestational age babies (odds ratio 8.84; 95% confidence interval 1.1-70.0; P = 0.007). The overall operative delivery rate was 85% with the caesarean section rate being 69%.

CONCLUSIONS

Women who become pregnant following oocyte donation should be considered obstetrically as high risk, especially those with ovarian failure because of the increased incidence of small-for-gestational age infants in these pregnancies. They are also at higher risk of pregnancy-induced hypertension and postpartum haemorrhage.

Initial and steady-state pharmacokinetics of a vaginally administered formulation of progesterone

OBJECTIVE

The pharmacokinetics of a 100 mg vaginal progesterone suppository was evaluated on days 1 and 7 and a 200 mg suppository on day 14. All the volunteers were given oral 17 beta-estradiol during the study.

STUDY DESIGN

Ten postmenopausal women volunteered for this study. Progesterone was given as a vaginal suppository. Peripheral venous samples were obtained at appropriate intervals and analyzed for 17 beta-estradiol and progesterone levels. Area under the curve for progesterone was assessed by the trapezoidal method. Statistical analysis was performed by a one-way analysis of variance.

RESULTS

Serum 17 beta-estradiol levels ranged from 22 to 182 pg/ml. Maximal serum progesterone levels ranged from 5.7 to 20.9 ng/ml, with the mean maximal levels 13.97, 16.09, and 12.68 ng/ml (not significantly different) and a mean area under the curve of 168.13, 207.64 and 227.71 ng/ml per hour on days 1, 7, and 14 (not statistically different).

CONCLUSIONS

These data indicate that vaginal absorption of progesterone is efficient. The lack of difference in the area under the curve for both doses suggests that the vaginal mucosa or the total surface area of the vagina may limit the absorption of progesterone from the vagina.

Cytogenetic, cellular, and developmental consequences of cryopreservation of immature and mature mouse and human oocytes

This study examined the effects of cryopreservation on cellular organization, chromosomal complement, and developmental potential of immature and mature mouse and human oocytes. Chromosomal analyses were performed by DNA fluorescence microscopy and karyotyping on the same metaphase II-stage oocytes before and after freezing. Cellular analyses involved electron microscopy, time-lapse video recording, and fluorescent-probe microscopy of cortical granules. The findings demonstrate that while profound cytoplasmic, nuclear, and nucleolar alterations occur in the immature oocyte during cryopreservation, an apparently normal nucleus and cytoplasm is re-established progressively after thawing and culture. The resulting oocytes mature at high frequency and for the mouse, are fertilizable and capable of normal preimplantation of embryogenesis. Cryopreservation of mature mouse and human oocytes is not accompanied by a significant increase in the frequency of aneuploidy. However, cryopreserved human oocytes, while fertilizable, arrest development during the early cleavage stages and display aberrant patterns of cytokinesis. The possible etiologies of developmental failure in the human embryo that may be related to oocyte cryopreservation, as well as the potential benefits of cryopreservation of the immature oocyte, are discussed with respect to clinical and commercial applications.

Obstetric performance of patients after oocyte donation

OBJECTIVE

The purpose of this study was to evaluate the obstetric performance of patients after oocyte donation.

STUDY DESIGN

A review of five patients in the author's private practice who underwent successful donation with conception and a literature review specific to obstetric outcome were undertaken.

RESULTS

All five patients were delivered of healthy infants; however, significant maternal complications occurred, particularly in two patients with twin gestations. A literature review substantiates increased incidence of (1) multiple gestation, (2) pregnancy-induced hypertension, (3) placenta previa, (4) preterm labor, and (5) cesarean birth. Infant outcomes, however, were good.

CONCLUSIONS

Women with premature ovarian failure and women over 40 years old can successfully conceive with oocyte and preembryo donation and successfully deliver healthy infants. More attention needs to be directed at maternal performance, particularly in those women over 40 years old.

Ovum donation--an overview

Ovum donation is now an integral part of the management of infertility, providing a solution for patients previously considered permanently infertile. The indications now include not only patients with premature ovarian failure, but also patients who are carriers of genetic disorders, patients with repeated failures in IVF, and patients after surgical castration and after X-ray therapy or chemotherapy. OD is simpler than IVF and has better pregnancy and delivery rates per transfer. Yet this modality of treatment raises serious legal, social, religious, and ethical issues such as the maximal age for treatment and donor selection; these aspects are discussed elsewhere (70).

Transplantation of fetal germ cells

Oogonial stem cells are short-lived and endow the ovary with its lifetime store of follicles during fetal life. No compensatory mechanisms exist to replace germ cells that are lost for whatever reason after birth. Fetal germ cells and the abundant primordial follicles of immature animals can be successfully stored at low temperatures and transplanted to hosts to generate normal ovulatory cycles. Sterilized hosts are restored to fertility. Such results suggest that the abundant reserves of germ cells in the ovaries of human abortuses offer opportunities for treating patients whose sterility is due to afollicular ovaries uncomplicated by autoimmune disease. The prospects for this treatment depend largely on the vigilance of the recipient's immune system and public attitudes to a radical treatment, though one that promises to overcome sterility and hypoestrogenism in women with either premature menopause or gonadal dysgenesis.