Ovarian hyperstimulation syndrome: an analysis of patient characteristics in the Asian population

INTRODUCTION

We aimed to identify the variables associated with ovarian hyperstimulation in Asian patients and compare them with western standards.

METHODS

This is a retrospective case record analysis of 79 patients with ovarian hyperstimulation at a tertiary restructured hospital.

RESULTS

Gonadotropin doses resulting in hyperstimulation did not vary between long and antagonist cycles in women less than 35 years with polycystic ovaries (PCO). Mean oestradiol levels at hyperstimulation were not different between PCO and non-PCO patients in a long cycle. Hyperstimulation was mostly due to higher starting doses. Total follicle counts of more than 20 on Day 5-7 after stimulation may be predictive of subsequent hyperstimulation. Hyperstimulation tended to be more severe in lean PCO patients, and prophylactic albumin helped to reduce its severity.

CONCLUSION

Gonadotropin doses at stimulation should start at 150 iu or less in women below 35 years of age, with a step up of 37.5 iu, as necessary. Transfer should be abandoned in the presence of high oestradiol levels (more than 5,000 pg/ml), when the total number of intermediate and large follicle count exceeds 30 on the day of oocyte retrieval, or when more than 19 eggs are retrieved. Variables in the Asian population appear to be similar to those in the western population.

Molar pregnancy with false negative urine hCG: the hook effect

Urine pregnancy tests are widely used in emergency departments as the first screening test for patients of reproductive age presenting with gynaecological problems in order to rule out pregnancy. Conditions such as complete molar pregnancy, which produces large amounts of beta human chorionic gonadotropin (beta-hCG), may cause a false negative result due to an oversaturation of the assay system, known as the "hook effect". We report a case where the exclusion of pregnancy by urine testing led to the initial misdiagnosis of a molar pregnancy as a degenerative fibroid. Physicians need to be reminded of the possibility of false negative results with this commonly used test. Negative or inconclusive results in patients with a high suspicion of pregnancy should be further evaluated by serum quantification of beta-hCG and appropriate sample dilution.

Growth hormone deficiency and supplementation at in-vitro fertilisation

INTRODUCTION

This study aims to evaluate the differences in oocyte stimulation, endometrial thickness, fertilisation rate and embryo quality at in-vitro fertilisation (IVF) in patients with documented growth hormone (GH) deficiency, after GH supplementation.

METHODS

This was a retrospective analysis of 20 cases of patients who were pregnant and had GH supplementation during IVF at the Singapore General Hospital between 1993 and 2003. All these patients had previously failed IVF due to poor stimulation, poor egg quality, poor fertilisation at intracytoplasmic sperm injection (ICSI) or failed implantation, and they had documented GH deficiency. These initial cycles were compared with their subsequent IVF cycles with GH supplementation. A non-parametric test was used for statistical analysis.

RESULTS

Embryo quality, determined by scoring the embryos on Day two using morphology, improved significantly after supplementation of GH (p-value is less than 0.001, median embryo score increased from 10.7 to 16). There was also a statistically significant increase in the fertilisation rate for those patients who had ICSI. There was no statistical difference in the number of oocytes retrieved or in the mean endometrial thickness with GH.

CONCLUSION

This study implies that GH supplementation may improve embryo quality in selected patients with GH deficiency. Its role in improving fertilisation rate at ICSI merits further research and evaluation.

Pregnancy outcomes from in-vitro fertilisation and intracytoplasmic sperm injection: a comparison

INTRODUCTION

The purpose of this study was to compare the obstetrical course of in-vitro fertilisation pregnancies with and without intracytoplasmic sperm injection, and to ascertain any difference in the outcome. Both singleton and multiple pregnancies were assessed individually in areas where they could confound results.

METHODS

This was a retrospective analysis of all successful in-vitro fertilisation pregnancies at the Singapore General Hospital during the period 1998-2003. A total of 271 pregnancies with and without intracytoplasmic sperm injection were evaluated. The details of the pregnancies were obtained from the Assisted Reproductive Technology Registry and Birth Defects Registry.

RESULTS

The obstetrical outcome was comparable between the two groups, in terms of the number of deliveries, biochemical and ectopic pregnancies. There was no significant difference in the miscarriage rate. The preterm rates for an intracytoplasmic injection pregnancy were two times higher than that reported in literature for both singletons and multiple pregnancies. The singleton intracytoplasmic sperm injection pregnancies were more likely to deliver preterm (17.5 percent, p-value is 0.041) compared to the ones without intracytoplasmic injection (5.7 percent). The average singleton birth weight was lower for the former (2.94 [+/-0.53] kg) than for the latter (3.19 [+/-0.48] kg, p-value is 0.0173). No definite conclusion could be reached regarding the differences in congenital abnormalities between the two groups.

CONCLUSION

The obstetrical course of an in-vitro fertilisation pregnancy with intracytoplasmic sperm injection pregnancy appears to be similar to one without intracytoplasmic sperm injection except for a slight increase in the preterm deliveries and a lower birth weight at delivery among the singletons.

Brain metastases from epithelial ovarian cancer

Brain metastasis from epithelial ovarian cancer is uncommon. We studied the presentation, treatment, and prognosis of brain metastasis in a single institution. A retrospective review of clinical details kept in the computer database of gynecologic oncology services in a tertiary institution between 1993 and 2003 was done. A Medline search for English publications on brain metastasis from epithelial ovarian cancer was performed from 1966 to 2003. The study period included 605 patients, and 4 (0.66%) patients developed brain metastases. The patients were usually well, until they presented with hemiparesis. The median primary treatment to brain metastasis interval was 16.5 months. Three out of four cases had multiple brain metastases, and all had small-volume extracranial tumor relapses. Serum CA125 measurement was not reliable in the screening for brain metastasis. The median survival after brain metastasis was 19.5 months. Single brain metastasis can be treated with surgery. Our experience supports the prevalent published opinion that all other cases should be considered for combined radiotherapy and surgery or radiotherapy and chemotherapy. Surveillance of tumor recurrence with serum CA125 monitoring does not predict brain metastasis, which carries a poor prognosis. The best mode of management of these patients is yet to be determined. Large study with multicenter participation to establish the standard treatment is urgently needed.