Immunomodulation for unexplained recurrent implantation failure: where are we now?

In brief

Immune dysfunction may contribute to or cause recurrent implantation failure. This article summarizes normal and pathologic immune responses at implantation and critically appraises currently used immunomodulatory therapies.

Abstract

Recurrent implantation failure (RIF) may be defined as the absence of pregnancy despite the transfer of ≥3 good-quality blastocysts and is unexplained in up to 50% of cases. There are currently no effective treatments for patients with unexplained RIF. Since the maternal immune system is intricately involved in mediating endometrial receptivity and embryo implantation, both insufficient and excessive endometrial inflammatory responses during the window of implantation are proposed to lead to implantation failure. Recent strategies to improve conception rates in RIF patients have focused on modulating maternal immune responses at implantation, through either promoting or suppressing inflammation. Unfortunately, there are no validated, readily available diagnostic tests to confirm immune-mediated RIF. As such, immune therapies are often started empirically without robust evidence as to their efficacy. Like other chronic diseases, patient selection for immunomodulatory therapy is crucial, and personalized medicine for RIF patients is emerging. As the literature on the subject is heterogenous and rapidly evolving, we aim to summarize the potential efficacy, mechanisms of actions and side effects of select therapies for the practicing clinician.

Among high responders, is oocyte development potential different in Rotterdam consensus PCOS vs non-PCOS patients undergoing IVF?

PURPOSE

To evaluate the oocyte potential to develop to blastocyst in Rotterdam consensus PCOS in women with hyper-responses requiring freeze-all embryos.

METHODS

Retrospective, single-academic center, cohort study of 205 patients who underwent freeze-all antagonist IVF cycles for OHSS risk between 2013 and 2019. Women in the PCOS group (n = 88) were diagnosed per the 2003 Rotterdam criteria. Control patients (n = 122) had no evidence of hyperandrogenism or menstrual disturbance. Data was compared by t-tests, chi-squared tests, or multivariate logistic regression (SPSS). Frozen blastocysts were Gardner's grade BB or better.

RESULTS

There was no difference in terms of number of oocytes collected (PCOS vs non-PCOS 27.7 ± 9.4 vs 25.9 ± 8.2, p = 0.157), number of MII (20.7 ± 8.0 vs 19.1 ± 6.6, p = 0.130), number of 2PN fertilized (15.6 ± 7.4 vs 14.4 ± 5.9, p = 0.220), and number of frozen blastocysts (7.8 ± 4.9 vs 7.1 ± 3.8, p = 0.272). In addition, fertilization rates (74 ± 17% vs 75 ± 17%, p = 0.730), blastulation rates per 2PN (51 ± 25% vs 51 ± 25%, p = 0.869), and blastulation rates per mature oocytes (37 ± 18% vs 37 ± 15%, p = 0.984) were all comparable between PCOS and controls, respectively. Moreover, there was no difference when comparing PCOS and controls in pregnancy rates (45/81 vs 77/122, p = 0.28) and clinical pregnancy rates (34/81 vs 54/122, p = 0.75), respectively. Multivariate logistic regression controlling for confounders failed to alter these results.

CONCLUSION

PCOS subjects do not seem to have altered oocyte potential as measured by number of MII oocytes collected, fertilization, and blastulation rates when compared to high-responder controls, with similar magnitude of stimulation.

Geographic variation in semen parameters from data used for the World Health Organization semen analysis reference ranges

OBJECTIVE

To study geographic variations in sperm parameters using data from the trials that defined the reference ranges of the World Health Organization 2021 manual.

DESIGN

Retrospective evaluation of the data used to define the World Health Organization reference ranges.

SETTING

Not applicable.

PATIENT(S)

Data from 11 studies, including 3,484 participants across 5 continents.

INTERVENTION(S)

The data were divided according to geographic locations.

MAIN OUTCOME MEASURE(S)

Differences in sperm parameters.

RESULT(S)

The semen volume was significantly lower in samples from Asia and Africa than in other regions. The sperm concentration was the lowest in Africa and highest in Australia. The total motile sperm count (TMSC) and total motile progressive sperm count (TMPS) were significantly lower in Africa than in other regions. The TMSC and TMPS in Asia and the United States were significantly lower than in Europe and Australia. The 5th percentile of the sperm concentration was lowest in the United States (12.5 × 10⁶/mL). The 5th percentile for the normal sperm morphology was lowest in the United States (3%) and highest in Asia (5%). The 5th percentile for the TMSC and TMPS were lowest in Africa (TMSC, 15.08 million; TMPS, 12.06 million) and the United States (TMSC, 18.05 million; TMPS, 16.86 million) and highest in Australia (TMSC, 29.61 million; TMPS, 25.80 million).

CONCLUSION(S)

Significant geographic differences in sperm parameters exist, and regional fertility societies should consider adding their own reference ranges on the basis of local experience and treatment outcomes.

A comparison of frozen-thawed embryo transfer protocols in 2920 single-blastocyst transfers

OBJECTIVE

To assess the effect of frozen-thawed embryo transfer (FET) protocol on live-birth rate (LBR) and clinical pregnancy rate (CPR), in single-vitrified-blastocyst transfer MATERIALS AND METHODS: Retrospective cohort study with FET of a single-blastocyst embryos (n = 2920 cycles) thawed 2013-2018. FET protocols were natural cycles (NC-FET) (n = 147), artificial hormone replacement treatment cycles (HRT-FET) (n = 2645), and modified NC (mNC) with hCG triggering (n = 128). Primary outcome was LBR. Adjustment for age, embryo grade, year of freezing\thawing, infertility cause, and endometrial thickness was performed.

RESULTS

There were no significant differences between the groups with regard to female age, embryo grade, and endometrial thickness. LBR was higher in the mNC compared to HRT-FET cycles (38.3% vs. 20.9% P < 0.0001), and in the NC compared to HRT-FET cycles (34.7% vs. 20.9%, P = 0.0002). CPR was higher in the mNC compared to HRT-FET cycles (46.1% vs. 33.3% P = 0.0003), and in the NC compared to HRT-FET cycles (45.9% vs. 33.3%, P = 0.002). There was no significant difference in LBR or CPR between NC-FET and mNC-FET. Higher LBR with NC-FET and mNC-FET remained significant after adjusting for confounders (aOR 2.42, 95%CI 1.53-3.66, P < 0.0001).

CONCLUSION

The use of the convenient artificial HRT-FET cycles must be cautiously reconsidered in light of the potential negative effect on LBR when compared with natural cycle FET.

Effects of embryo retention during embryo transfer on IVF outcomes

PROPOSE

To investigate embryo retention (ER) rate in embryo transfer (ET) cycles and its effects on reproductive outcomes in a large database.

METHODS

A matched retrospective cohort study in a tertiary academic hospital-based reproductive center. A total of 15,321 ET cycles were performed from January 2008 to December 2018. Each woman was matched with three separate control subjects of the same age (± 1 year), embryo condition, main causes of infertility, and type of protocol used for fresh or frozen ET cycles. The main outcomes were ER rate, and implantation, clinical pregnancy, ectopic pregnancy, and live birth rates.

RESULTS

The overall incidence of ER was 1.4% (213/15,321). There was no difference in the rate of ER rate in fresh ET cycles compared with frozen transfer cycles (P = 0.54). We matched 188/213 (88%) of cases in the ER group to 564 non-ER cases. There were no cases of the blood in the catheter seen in the ER group. Pregnancy outcomes were similar between the ER and the non-ER cycles: clinical pregnancy rate (31.3% vs. 36.1%, P = 0.29), implantation rate (26.2% vs. 31.3%, P = 0.2), live birth rate (20.3% vs. 24%, P = 0.53), ectopic pregnancy rate (0.5% vs. 0.4%, P = 0.18), and miscarriage rate (10.7% vs. 11.3%, P = 0.53).

CONCLUSION

Our results suggest that ER rate does not affect the reproductive outcomes including clinical pregnancy rate, implantation rate, and live birth rate. Patients and physicians should not be concerned about the retention of embryos during transfer since there is no effect on pregnancy outcome.

The effect of LH rise during artificial frozen-thawed embryo transfer (FET) cycles

Purpose

To evaluate the association between a rise in serum luteinizing hormone (LH) levels during artificial frozen–thawed embryo transfer (FET) cycles and clinical pregnancy rate.

Methods

A retrospective cohort study of women undergoing artificial FET cycles. We compared cycles in which LH double itself from the early follicular phase and further (group A) to cycles without a rise in LH (group B). Endometrium preparation was achieved by administration of 2 mg three times per day estradiol valerate tablets. Embryo transfer (ET) was conducted after achieving endometrial thickness > 7 mm and vaginal progesterone was added according to the embryo’s age. A beta-hCG was measured 13–14 days after ET. Clinical pregnancy was diagnosed on transvaginal ultrasound.

Results

Data from 984-FET cycles were retrieved. LH, exogenous estradiol (E2), progesterone values, endometrial thickness, and pregnancy outcomes were available in all patients. From 984-FET cycles, 629 (63.9%) had a doubling, and 355 (36.07%) had no rise in LH. Patients mean age was 30 years, similar in both groups. A multivariable logistic regression analysis was calculated to assess the effect of LH rise and pregnancy outcomes, after adjusting for confounders including a rise in E2 level and endometrial thickness. In this model, there was no association between doubling LH values and pregnancy rates (adjusted odds ratio: 1.06, 95% CI: 0.75–1.5, P = 0.74).

Conclusion

LH rise during artificial FET cycles does not alter pregnancy rates. Apparently, hormonal monitoring of LH levels may not yield useful information in the artificial FET cycle and may be omitted.

Lay summary

Supplementation of estradiol, a hormone produced by the ovaries, starting at the beginning of the menstrual cycle of an artificially frozen embryo transfer (FET) can lead to a rise in luteinizing hormone (LH), the hormone that induces ovulation. Such a rise in LH may interfere with embryo implantation, the process where the embryo attaches to the inner lining of the uterus and, therefore, could affect the chances of pregnancy. The current study is the first to assess the effect of a dynamic rise in LH levels during FET cycles on pregnancy rates. This study found no difference in pregnancy rates between FET cycles where the LH doubled compared to cycles without such a rise in LH. Larger, prospective studies should be conducted to assess the impact of LH elevation on pregnancy outcomes.

An evaluation of changes over time in the semen parameters data used for the World Health Organization semen analysis reference ranges

BACKGROUND

Previous meta-analyses concluded that there is a decline in sperm parameters over time. This conclusion might be incorrect due to inherent biases or focusing only on a single parameter - sperm concentration.

OBJECTIVE

To study trends in sperm parameters over the past twenty years using data from the trials that defined the reference ranges of the World Health Organization manual.

MATERIALS AND METHODS

Retrospective evaluation of the data used to define the World Health Organization reference ranges. The data from 11 studies, including 3589 participants between 1996-2016, were divided into three period groups based on the decade of study. Differences in semen parameters' distribution were presented in boxplot. P-values were calculated by the Kruskal Wallis rank-sum test followed by Dunn post-hoc test. Analyses were conducted using the R programming language.

RESULTS

A small decrease was noted in mean sperm concentrations (88.1 million/ml, 87.6 million/ml and 77.2 million/ml for the first second and third decades respectively) (p<0.01). However, the 5^th percentile of sperm concentration for the third decade was higher than the first or second decades (18 million/ml vs. 14.9 million/ml and 15 million/ml respectively). No significant differences were noted in progressive motility over the years (p = 0.32). The percent of morphologically normal sperm decreased between the first (24.2%) and the second (12.6%) periods of the study (p<0.001) and then increased in the third decade (14.2%) (p<0.01). While TMC declined between the second and third decades (189 million and 153.9 million respectively, p<0.001), at levels unlikely to decrease fertility. However, the 5^th percentile of the TMC remained stable at 24.9, 20.8 and 20.6 million, for the first, second and third decades respectively (p = 0.36).

DISCUSSION AND CONCLUSION AND RELEVANCE

Trends in sperm parameters over the last three decades do not seem to be clinically significant. This article is protected by copyright. All rights reserved.

The Maternal Age Cut-Off for an Increase in Composite Adverse Outcomes

OBJECTIVE

To investigate whether there is a specific maternal age cut-off at which there is an increase in maternal and neonatal adverse outcomes.

METHODS

A retrospective study comparing maternal and neonatal outcomes between nulliparous women of different ages. The receiver operating characteristic model with the Youden index was used to find the best age cut-off using cesarean delivery (CD) and composite adverse outcomes. A multivariable logistic regression analysis was calculated after adjusting for smoking, induction of labour, epidural use, hypertensive disorders, gestational diabetes, and birth weight.

RESULTS

The study included 11 343 nulliparous women. Age 28 years was found to be the cut-off age at which we found a significant increase in adverse outcomes. Women older than age 28 years had a higher risk of CD than women younger than 28 years (35.7% vs. 21.3%, P < 0.0001). They were also more likely to deliver prematurely (11.9% vs. 7.9%, P < 0.0001) and had higher rates hypertensive disorders (2.3% vs. 1.1%, P < 0.0001) and gestational diabetes mellitus (0.4% vs. 0.1%, P = 0.001). Furthermore, their babies were more likely to be growth restricted (1.1% vs. 0.3%, P < 0.0001). There were no differences in the rates of induction of labour or macrosomia. After adjusting for confounders, we found that women older than 28 years had higher risks of CD and adverse outcomes than younger women (aOR 1.9; 95% CI 1.744-2.1 and aOR 1.6; 95% CI 1.6-1.77, respectively).

CONCLUSION

Increasing maternal age is independently associated with adverse maternal and neonatal outcomes with an age cut-off of 28 years. Women older than age 28 years are at higher risk for composite adverse outcomes than younger women.

Early exploration of COVID-19 vaccination safety and effectiveness during pregnancy: interim descriptive data from a prospective observational study

Objective

During December 2020, a massive vaccination program was introduced in our country. The Pfizer-BioNTech, BNT162b2 vaccine was first offered exclusively to high-risk population, such as medical personnel (including pregnant women). In this study we compare short term outcomes in vaccinated vs. non-vaccinated pregnant women.

Methods

In this prospective observational cohort study, vaccinated and non-vaccinated pregnant women were recruited using an online Google forms questionnaire targeting medical groups on Facebook and WhatsApp. A second questionnaire was sent one month after the first one for interim analysis. Our primary outcome was composite complications in vaccinated and non-vaccinated groups, considered any of the following: vaginal bleeding, pregnancy loss, hypertension, gestational diabetes, and preterm birth. Secondary outcomes included: vaccine side effects, diagnosis of COVID-19 since the last questionnaire, prevalence of vaccinated participants, and reasons for refusal to be vaccinated.

Results

Overall, 432 women answered the first questionnaire, of which 326 responses were received to the second questionnaire. Vaccination rate increased from 25.5% to 62% within a month. Maternal age, gestational age at enrollment, nulliparity and number of children were similar in both groups. The rate of composite pregnancy complications was similar between vaccinated and non-vaccinated group (15.8% vs 20.1%, p = 0.37), respectively. The risk for COVID-19 infection was significantly lower in the vaccinated group (1.5% vs 6.5%, p = 0.024, Odds Ratio: 4.5, 95% confidence interval 1.19–17.6).

Conclusions

mRNA vaccine during pregnancy does not seem to increase the rate of pregnancy complications and is effective in prevention of COVID-19 infection.

P–642 Does Conn’s syndrome (Primary hyper-aldosteronism) affect pregnancy and neonatal outcomes? A population based study of over 9 million deliveries

Study question

Does primary hyperaldosteronism(PA) confer an independent risk for adverse pregnancy or neonatal outcomes, based on analysis of the Healthcare-Cost and Utilization Project-Nationwide Inpatient Sample(HCUP-NIS) database?

Summary answer

After controlling for all significant confounders, women with PA are at increased risk for gestational hypertension, eclampsia, and operative vaginal delivery, but unexpectedly not preeclampsia

What is known already

PA is extremely rare in pregnancy, and our current knowledge regarding PA during pregnancy is derived only from case reports and series. No pregnancy control studies exist in the literature for this endocrinopathy. PA is characterized by autonomous aldosterone and suppressed rennin production from the adrenals. Caused by adenomas or hyperplasia, it presents with hypertension and hypokalaemia.

Study design, size, duration

This is a retrospective population-based cohort study utilizing data from the HCUP-NIS from 2004 to 2014, inclusively. A cohort of all deliveries during the study period was created. Within this group, all deliveries to women with PA were identified as part of the study group (n = 102), and the remaining deliveries were categorized as the reference group (n = 9,096,686).

Participants/materials, setting, methods

HCUP-NIS is the largest inpatient sample database in the USA and is comprised of hospital stays throughout the country. It provides information relating to seven million inpatient stays yearly, includes 20% of admissions, and represents over 96% of the American population. Multivariate logistic regression, controlling for confounders, was conducted to explore associations between PA and delivery outcomes. According to the Tri-Council Policy Statement (2018), IRB-approval was not required, given data was anonymous and publicly available.

Main results and the role of chance

Women with PA were older(P = 0.0001), more likely obese(10.8% vs. 3.6%), with higher rates of chronic hypertension(53.9% vs. 1.8%), thyroid disease(15.7% vs. 2.5%), pre-gestational diabetes(5.9% vs. 1%)(all P = 0.0001), and were more commonly African American and not Hispanic(P = 0.04) than the controls. There was no statistical difference between the two groups in the other demographic features including; income distribution(P = 0.45), hospital type (P = 0.63), rates of smoking(P = 0.99), illicit drug use(P = 0.73) or use of assisted reproductive technology(P = 0.94). After adjustment for significant confounders women with PA were more likely to experience gestational hypertension(aOR 3.6 95%CI:1.6–8.1, P = 0.001) and eclampsia(aOR 19.0, 95%CI:2.6–138.2, P = 0.004). Moreover, women with PA were more likely to deliver by operative vaginal delivery(aOR 9.7 95%CI:6.3–15.1, P = 0.0001). However, there was no increased risk for preeclampsia in women with PA(aOR 1.47 95%CI:0.78–2.76, P = 0.23). This finding was consistent even when not controlling for confounding effects including pre-gestational hypertention(OR 0.81 95%CI:0.26–2.56, P = 0.72. There were no differences in the number of women with PPROM(P = 0.81), preterm delivery(P = 0.88), placental abruptio(P = 0.7), maternal death(P = 0.99), hysterectomy(P = 0.99), cesarean section(P = 0.76), chorioamnionitis(P = 0.99), postpartum hemorrhage (P = 0.53), maternal infection(P = 0.99), pulmonary embolism(P = 0.99) or disseminated intravascular coagulation(P = 0.99) between the two groups. Furthermore, there was no difference in other neonatal outcomes including: small for gestational age(P = 0.18), fetal demise(P = 0.85) or congenital anomalies(P = 0.15).

Limitations, reasons for caution

This is a retrospective analysis utilizing an administrative database that relies on data coding accuracy and consistency.

Wider implications of the findings: Women with PA were more likely to experience adverse pregnancy outcomes, including gestational hypertension, eclampsia, and operative vaginal deliveries. Neonatal complications were not increased in PA. Surprisingly, there was no increased risk for preeclampsia in women with PA, which needs to be further studied.

Trial registration number

NA

Is controlled ovarian stimulation and insemination an effective treatment in older women with male partners with decreased total motile sperm counts?

OBJECTIVE

To assess the effect of the total motile sperm counts (TMSC) on the success of controlled ovarian stimulation (COH) and intra-uterine insemination (IUI) in women 38-42 years of age.

STUDY DESIGN

A database of all women aged 38-42 years who underwent IUI with stimulation at a University Reproductive Centre between 2009 and 2018 inclusive was developed. Including stimulation with clomiphene citrate, letrozole or gonadotropins and divided into TMSC 5.00-10.0 mil and < 5.00 mil. Statistics were compared with multivariate logistic regression, t tests or Chi-squared tests.

RESULTS

A total of 397 cycles of IUI in 397 patients were included, of which, 190 cycles with TMSC 5.00-10.0 and 207 cycles with TMSC < 5.00. There were no statistical differences in the baseline characteristics between the two groups including: age (P = 0.2), gravidity (P = 0.7), parity (P = 0.6), basal FSH (P = 0.2), basal E2 (P = 0.4), antral follicular count (P = 0.5) and the number of mature follicles stimulated (P = 0.2). As expected, TMSC was 7.6 ± 1.5 mil in the first group and 2.4 ± 1.6 mil in the second group (P < 0.0001). The clinical pregnancy rate per cycle in the 5.01-10.00 TMSC group was 9.5 vs. 3.4% when TMSC < 5.00 (P = 0.01). When evaluating only women 40-42 years of age (99 women in the 5.00-10.00 TMSC group and 95 in the group of TMSC < 5.00); the pregnancy rates were not statistically different between the two groups (7 vs. 7.3%, P = 1), nor was the clinical pregnancy rate (5 vs. 6.3%, P = 0.7).

CONCLUSIONS

Women 38-39 years of age have poorer outcomes at COH/IUI when TMSC < 5 million than if it is 5-10 million. Once a woman is 40 years of age, this effect is lost. With TMSC 5-10 million, women 38-39 years of age have respectable outcomes at COH/IUI. Clinical pregnancy rates are very low in women 40 years of age with TMSC ≤ 10 million or 38-39 years old with TMSC < 5 million and other treatments should be offered.

Are we preventing the primary cesarean delivery at the second stage of labor following ACOG-SMFM new guidelines? Retrospective cohort study

OBJECTIVE

In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) published an Obstetric Care Consensus for safe prevention of primary cesarean delivery. We aimed to assess whether these guidelines decreased the primary CD rate during the second stage of labor, in our department.

DESIGN, SETTING, AND POPULATION

A retrospective cohort study of all women reaching the second stage of labor, at term, in a single university-affiliated medical center between2010 and 2017.

METHODS

We compared maternal and neonatal outcomes over three year's periods:-pre-guidelines (2010-2013) vs. 2nd period - post-guidelines (2014-2017).

THE MAIN OUTCOME MEASURES

CD rate at 2ndstage of labor.

RESULTS

The study included 11,464 women. The CD rate in the 2nd stage of labor has increased significantly from 4% to 5.9% in the post-guidelines period (OR 1.48, 95% CI 1.16-1.89, p = .001). After a sub-analysis of specific subgroups, and adjustment for confounders, the increase was solely observed in nulliparous women (aOR 1.418, 95% CI 1.067-1.885, p = .016). Furthermore, increased odds for vaginal operative delivery were observed in the multiparous women in the post-guidelines period (2.7% vs. 4.1%, p = .046).

CONCLUSIONS

The implementation of the new ACOG and SMFM guidelines was not associated with a change in the CD rate performed at the 2nd stage of labor in the whole study population. However, there was a rise in the CD rate performed at the 2nd stage in nulliparous women. Furthermore, there was an increase in operative deliveries in the whole study population, especially in multiparous women, without an apparent increase in other immediate adverse neonatal or maternal outcomes.

Induction of labor versus expectant management among women with macrosomic neonates: a retrospective study

Background: The macrosomic fetus predisposes a variety of adverse maternal and perinatal outcomes. Although older studies have shown no benefit in inducing women of suspected macrosomic fetuses, more updated studies show different information.Objectives: The aim of our study was to compare induction of labor versus expectant management among women with macrosomic neonates weighing more than 4000 g at term (between 37°^/7 and 41^6/7 weeks' gestation).Study design: This was a retrospective cohort study of all live-born singleton pregnancies with macrosomic newborns who were delivered at our institution between 1 January 2000 and 1 June 2015. We compared the outcomes of induction of labor, at each gestational age (GA), between 37 and 41 weeks (study group) with ongoing pregnancy. The primary outcome was cesarean section (CS) rate. Secondary outcomes were composite maternal and neonatal outcome and birth injuries.Results: Overall, out of 3095 patients with macrosomic newborns who were included in the study, 795 women (25.7%) underwent induction of labor. The cesarean section rate was not found to be significantly different between the groups at all gestational ages, nor was the vaginal delivery rate. After adjusting for confounders, induction of labor at 40 and 41 weeks' gestation was associated with composite maternal outcome (adjusted odds ratio (aOR) 1.6, 95% confidence interval (CI): 1.3-2.1; aOR 1.7, 95% CI: 1.3-2.2, respectively) and composite neonatal outcome (aOR 1.6, 95% CI: 1.1-2.4; aOR 1.8, 95% CI: 1.1-2.9). Induction of labor at 40 weeks' gestation was also associated with increased risk of birth injuries (aOR 2.9, 95% CI: 1.4-6).Conclusions: Compared with ongoing pregnancy, induction of labor of women with macrosomic neonates between 37 and 41 weeks of gestation does not reduce the CS rate, nor does it increase the vaginal delivery rate. Moreover, induction of labor of those women beyond 39 weeks' gestation is associated with composite adverse maternal/neonatal outcome, specifically birth injuries.

Primary Papillary Serous Carcinoma of the Fallopian Tube Presenting as a Vaginal Mass: A Case Report and Review of the Literature

BACKGROUND There is now evidence to support that some cases of high-grade serous papillary carcinoma arise from the fallopian tubes rather than the ovaries. Common symptoms at presentation include abdominal pain and swelling, vomiting, altered bowel habit and urinary symptoms. To our knowledge, this is the first case of serous papillary carcinoma presenting as a vaginal mass lesion. CASE REPORT A 41-year-old woman was referred to the Bnai-Zion Medical Center with the main complaint of irregular vaginal bleeding, vaginal mucous discharge, and suspected pelvic mass. Physical examination showed a soft, painless mass, measuring about 10 cm in diameter located mainly in the recto-vaginal septum, but not involving the uterus. Ultrasound examination showed no abnormal ovarian or uterine findings. Transvaginal biopsies of the mass showed a poorly differentiated serous papillary carcinoma of ovarian, tubal, or peritoneal origin. The physical examination and imaging findings strongly indicated an inoperable tumor, and the patient was treated with neoadjuvant (pre-surgical) chemotherapy. Pre-operative computed tomography (CT) imaging showed the partial involvement of the colon, and so surgical treatment included total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, partial vaginectomy, anterior rectal resection, and lymph node dissection. Histopathology of the surgical specimens showed a poorly differentiated serous carcinoma originating from the fimbria of the right fallopian tube. CONCLUSIONS To the best of our knowledge, this is the first report to describe primary fallopian tube papillary serous carcinoma presenting as a vaginal mass. Therefore, physicians should be aware of this possible diagnosis.