Young-onset diabetes in women with Polycystic Ovary Syndrome: A territory-wide retrospective analysis in Hong Kong

AIM

To ascertain the risk of progression to diabetes among Chinese women with PCOS.

METHODS

Women with PCOS (n = 3978) were identified from the Hong Kong Diabetes Surveillance Database based on the ICD-9 code for PCOS diagnosis and women without PCOS served as controls (n = 39780), matched 1:10 by age.

RESULT(S)

The mean follow-up was 6.28 ± 4.20 and 6.95 ± 4.33 years in women with PCOS and controls, respectively. The crude incidence rate of diabetes was 14.25/1000 person-years in women with PCOS compared with 3.45 in controls. The crude hazard ratio of diabetes in women with PCOS was 4.23 (95 % CI: 3.73-4.80, p < 0.001). Further stratified by age group, the risk of developing diabetes decreased with increasing age but it remained significantly higher in women with PCOS across all age groups. It also suggested that the incidence rate of diabetes in women with PCOS aged 20-29 is highly comparable to that in healthy women aged ≥ 40. More than half of the incident diabetes captured during the follow-up in women with PCOS cohort were young-onset diabetes.

CONCLUSION

Women diagnosed with PCOS at a younger age have the highest relative risk of developing diabetes, suggesting frequent glycemic status screening is required to detect diabetes at an early stage.

Association between FGF19, FGF21 and lipocalin-2, and diabetes progression in PCOS

Women with polycystic ovary syndrome (PCOS) have an increased risk of developing type 2 diabetes. FGF19, FGF21 and lipocalin-2 have emerged as important markers of metabolic risk. This study aims to compare the levels of FGF19, FGF21 and lipocalin-2 between subjects with or without PCOS, and to investigate the relationship between proteins and diabetes progression. In this nested case-control cohort study, 128 Chinese PCOS women and 128 controls were recruited and followed-up. All subjects underwent the oral glucose tolerance test for the evaluation of glycaemic status. Baseline serum protein levels were measured using ELISA. Compared with controls, PCOS subjects had higher levels of FGF19 (P < 0.001) and FGF21 (P = 0.022), but had lower lipocalin-2 (P < 0.001). In total, 20.8% of PCOS and 9.2% of controls developed diabetes over a mean duration of 10.4 ± 1.2 and 11.3 ± 0.5 years, respectively. Logistic regression analyses suggested FGF19 was positively associated with diabetes progression in controls, after adjusting for age, follow-up duration, waist and fasting glucose (P = 0.026, odds ratio (OR) (95% CI): 7.4 (1.3-43.6)), and the positive relationship between FGF21 and diabetes progression in controls was attenuated by adjusting for age and follow-up duration (P = 0.183). Lipocalin-2 was positively correlated with diabetes progression in PCOS group (P = 0.026, OR (95% CI)): 2.5 (1.1-5.6)); however, this became attenuated after adjusting for waist and fasting glucose (P = 0.081). In conclusion, there is differential expression of FGF19, FGF21, and lipocalin-2 in PCOS. The serum level of FGF19, and FGF21 is associated with diabetes progression in women without PCOS, while lipocalin-2 was related to diabetes progression in PCOS women.

Assisted reproduction technology and long-term cardiometabolic health in the offspring

Ronald Ma and co-authors discuss Emma Norrman and colleagues' accompanying research study on the health of children born with assisted reproductive technology.

Embryo migration following ART documented by 2D/3D ultrasound

Embryos have traditionally been thought to implant at the exact site they are transferred during assisted reproductive technology (ART). The introduction of 2D/3D ultrasound has allowed for mapping of the transfer site using air bubbles as a surrogate marker of embryo location. This study's aim was to compare the location of embryo transfer (ET) on ultrasound to that of embryo implantation. We present four cases of ectopic pregnancy at four sites: tubal, cervical, interstitial and ovarian. We compare the site of implantation on 2D/3D ultrasound at six weeks of pregnancy to that of transfer as assessed on 2D/3D ultrasound. In all four cases, the embryo flash was visualised in the centre of the uterine cavity on ultrasound at ET. At six weeks of pregnancy, the uterine cavity was empty and an ectopic pregnancy was identified. The tubal and ovarian ectopics were managed surgically whilst the cervical and interstitial pregnancies were treated with systemic methotrexate. These cases demonstrate embryo implantation distal to the ultrasound-confirmed site of transfer. These cases provide visually compelling evidence of embryo migration following ET and lend support to the theory that ectopic pregnancy may occur as a result of embryo migration, rather than poor ET technique.

Ovarian HBV replication following ovulation induction in female hepatitis B carriers undergoing IVF treatment: A prospective observational study

Hepatitis B virus (HBV) can be found in ovarian tissues. This study compared HBV DNA levels in follicular fluid collected during oocyte retrieval with paired serum samples in HBV carriers after ovarian stimulation during IVF treatment for infertility. Sixty-four HBV carrier women referred to the Assisted Reproductive Units of two Hong Kong hospitals were recruited. At oocyte retrieval, the follicular fluid aspirated from the first follicle was collected for study. In 22 women, the first follicular fluid sample from both ovaries was similarly collected and studied. These women were also tested for liver function test and HBeAg. In 28 (43.8%) women, HBV DNA was detected in follicular fluid and the level correlated with serum levels (Spearman's correlation P < .001). There was concordant detection of HBV DNA in both ovaries, and the levels were significantly correlated (Spearman's correlation P = .029). In 40% of women with FF HBV DNA, the follicular fluid:serum ratio was >1.0, suggesting stimulation of HBV replication. These women also had significantly different liver function test results. Increased HBV replication exists in 40% of women with HBV DNA detected in follicular undergoing ovarian stimulation during IVF treatment.

Presence of Hepatitis B virus DNA in follicular fluid in female Hepatitis B carriers and outcome of IVF/ICSI treatment: A prospective observational study

OBJECTIVE

To determine the relationship between the presence of detectable HBV DNA in the follicular fluid in HBV carriers with IVF/ICSI treatment outcome.

STUDY DESIGN

A prospective observational study conducted in the Assisted Reproductive Unit, a tertiary referral centre affiliated with the Department of Obstetrics and Gynecology, The Chinese University of Hong Kong; and the Union Reproductive Medicine Centre at Union Hospital, Hong Kong. The primary outcome measure was pregnancy rate. Secondary outcome measures were the prevalence of detectable HBV DNA in the follicular fluid, implantation rate, clinical pregnancy rate, ongoing pregnancy rate and live birth rate.

RESULTS

HBV DNA was detected in the follicular fluid of 28 (43.8%) of the 64 women, and the mean level in this group in log₁₀ copies/mL (±SD) was 4.36 ± 1.85. Women with detectable follicular fluid HBV DNA were younger, lighter, had longer duration of infertility, higher incidence of detectable serum HBV DNA (OR 4.592, 95% C I 2.333-9.038), and significantly wider range in the number of total fertilized, viable embryos, and blastocyst rate, but no difference in cycle characteristics, stimulation and pregnancy outcomes, although the almost doubled ongoing pregnancy/live birth rate per cycle initiated (60.7% versus 38.9%) failed to reach statistical significance due to the small numbers.

CONCLUSION

Our results suggested HBV infection did not appear to be detrimental to the outcome of IVF/ICSI treatment.

Effect of mid-follicular phase recombinant LH versus urinary HCG supplementation in poor ovarian responders undergoing IVF - a prospective double-blinded randomized study

Luteinizing hormone (LH) is crucial for the development of follicular growth and oocyte maturation, especially in the management of poor ovarian responders (PORs). This study presents the results of a prospective double-blinded randomized study to compare the effect of mid-follicular phase recombinant LH (rLH) supplementation with urinary human chorionic gonadotrophin (uHCG) supplementation when using a fixed gonadotrophin-releasing hormone (GnRH) antagonist protocol in IVF cycles. A total of 49 women with poor ovarian response (POR) according to the Bologna criteria were recruited. This study showed no statistically significant difference in cycle cancellation rates, numbers of oocytes retrieved per cycle initiated, fertilization rates, the numbers of embryos obtained per cycle initiated, implantation, clinical pregnancy and live birth rates, although the live birth rate per cycle initiated in the uHCG group (29.2%) was 3.6 times that of the rLH group (8.0%). Further studies are required to verify if uHCG supplementation produces better clinical outcomes compared with rLH in women with POR.

The reproductive and metabolic effect of rosiglitazone on Chinese women with polycystic ovarian syndrome--a double-blind randomized placebo-controlled study

OBJECTIVE

To investigate whether an insulin sensitizer has any effect on amenorrhea and clinical and biochemical hyperandrogenism in Chinese women with polycystic ovarian syndrome (PCOS).

DESIGN

Randomized controlled double-blind trial.

SETTING

A tertiary referral center, Hong Kong.

PATIENT(S)

Chinese women who fulfilled the Rotterdam criteria of PCOS (n = 70).

INTERVENTION(S)

Rosiglitazone 4 mg daily for the first month followed by 4 mg twice daily for 11 months.

MAIN OUTCOME MEASURE(S)

Menstrual status as well as clinical and biochemical hyperandrogenism.

RESULT(S)

There is a significantly higher rate of regular menses among the treatment arm (16 [50.0%] of 32 vs 4 [11.8%] of 34) at 6 months and the improvement appeared to be sustained (10 [41.7%] of 24 vs 6 [20.0%] of 30) at 12 months. There was no change in the acne and hirsutism scores as well as serum T levels in both arms.

CONCLUSION(S)

We found a possible benefit in menstrual cyclicity but a lack of improvement in hyperandrogenism in our Chinese population.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-TRC-09000670 (Chinese Clinical Trial Registry).

Sonographic measurement of mesenteric fat predicts presence of fatty liver among subjects with polycystic ovary syndrome

OBJECTIVE

Visceral fat is believed to be important in the pathogenesis of metabolic syndrome and fatty liver. In this study, we examined the relationship between mesenteric fat thickness and other sonographic indices of adiposity and the presence of fatty liver among subjects with polycystic ovary syndrome (PCOS).

SUBJECTS AND METHODS

A total of 117 Chinese subjects with PCOS were evaluated (mean age, 28.6 ± 6.5 yr; mean body mass index, 24.3 ± 5.3 kg/m(2)). Anthropometric measurements and metabolic risk profile, including a standard oral glucose tolerance test, were assessed in all subjects. All subjects underwent an ultrasound examination for measurement of thickness of mesenteric, preperitoneal, and sc fat as well as evaluation for fatty liver.

RESULTS

Forty-six (39.3%) of the subjects had fatty liver. PCOS subjects with fatty liver had higher body mass index, waist circumference, waist-hip ratio, and systolic blood pressure; a more unfavorable lipid profile with higher triglyceride; lower high-density lipoprotein cholesterol; higher fasting glucose and insulin; higher 2-h glucose during oral glucose tolerance test; lower SHBG; and higher alanine aminotransferase. Subjects with fatty liver had increased thickness of preperitoneal, mesenteric, and sc fat, as well as increased carotid intima-media thickness. Abdominal fat thickness showed moderate correlation to alanine aminotransferase as well as fasting insulin. On multivariate logistic regression, fasting insulin and mesenteric fat thickness were identified as independent predictors of fatty liver among subjects with PCOS.

CONCLUSION

Fatty liver is present in a significant proportion of Chinese patients with PCOS. Sonographic measurement of mesenteric fat is an independent determinant of fatty liver among subjects with PCOS and identifies subjects at increased cardiovascular risk.

Effects of laparoscopic ovarian drilling in treating infertile anovulatory polycystic ovarian syndrome patients with and without metabolic syndrome

OBJECTIVE

To compare the effects of laparoscopic ovarian drilling in treating infertile polycystic ovarian syndrome in patients with and without metabolic syndrome.

DESIGN

Retrospective review.

SETTING

A university-affiliated hospital in Hong Kong.

PATIENTS

A total of 89 infertile anovulatory polycystic ovarian syndrome patients, who underwent laparoscopic ovarian drilling with completed metabolic screening and seen over a 5-year period from 2002 to 2007.

MAIN OUTCOME MEASURES

The clinical, hormonal, and metabolic characteristics as well as spontaneous ovulation rates, reproductive outcomes, and diabetes risks during pregnancy observed after laparoscopic ovarian drilling.

RESULTS

Approximately one fifth (21%) of polycystic ovarian syndrome patients had the metabolic syndrome. There were no differences in spontaneous ovulation rates (68% vs 61%, P=0.76), cumulative pregnancy rates (68% vs 61%, P=0.77), and diabetes risks during pregnancy (64% vs 42%, P=0.13) between patients with and without metabolic syndrome.

CONCLUSION

Laparoscopic ovarian drilling was equally effective in inducing ovulation in polycystic ovarian syndrome patients with metabolic syndrome. Thus, patients with metabolic syndrome should not be precluded from laparoscopic ovarian drilling, which has the additional advantage of enabling full tubo-peritoneal assessment at the same time.

Comprehensive assessment of serum estradiol impact on selected physiologic markers observed during in-vitro fertilization and embryo transfer cycles

OBJECTIVE

This investigation assessed the effect of serum estradiol levels on outcomes of in-vitro fertilization and embryo transfer (IVF) cycles.

MATERIALS AND METHOD

This was a retrospective cohort study of 1123 IVF cycles comparing impact of estradiol (E(2)) levels on follicular development, fertilization, embryo quality, implantation, pregnancy rate, miscarriage rate, and selected obstetric complications.

RESULTS

We found high serum E(2) levels to be significantly associated with increased number of mature follicles and mature oocytes retrieved (p<0.01, for both). E(2) levels were also associated with more viable and good-quality embryos (p<0.01). There was no significant impact of E(2) on oocyte maturation, fertilization rate, embryo quality, or overall pregnancy rates. Moreover, high E(2) levels were significantly associated with higher implantation rates and reduced incidence of miscarriage (p<0.05, for both).

CONCLUSION

Within the safety range in clinical practice, our data demonstrate a generally positive effect of high serum E(2) on selected IVF parameters.

Effects of early luteal-phase vaginal progesterone supplementation on the outcome of in vitro fertilization and embryo transfer

OBJECTIVE

To determine whether early luteal-phase vaginal progesterone supplementation improves the outcome of in vitro fertilization-embryo transfer (IVF-ET).

METHODS

A randomized, controlled trial was conducted on 197 women undergoing IVF-ET cycles with human chorionic gonadotropin (hCG) as the standard luteal-phase support. The participants were randomly assigned to either the study group or the control group. The study group was given 200 mg micronized progesterone vaginally three times per day starting in the afternoon of oocyte retrieval until the morning of embryo transfer, in addition to the standard hCG luteal-phase support. The control group received only the hCG support. The pregnancy rates and the implantation rates were measured.

RESULTS

There were no significant differences in pregnancy rates or implantation rates between groups. However, subgroup analysis revealed significantly higher pregnancy and implantation rates in the study group among those women with fibroids or difficult oocyte retrieval involving uterine puncture (38.7% vs. 15.4% and 26.8% vs. 9.4% respectively, both p = 0.04).

CONCLUSION

Additional early luteal-phase vaginal progesterone supplementation may improve the outcome of IVF-ET in women with fibroids or difficult oocyte retrieval.

Polycystic ovarian syndrome in Hong Kong Chinese women: patient characteristics and diagnostic criteria

OBJECTIVES

To identify the characteristics of Hong Kong Chinese women with polycystic ovarian syndrome and to compare different diagnostic criteria.

DESIGN

Retrospective study.

SETTING

Gynae-endocrinology Clinics in the Prince of Wales Hospital, Hong Kong.

PATIENTS

Ninety Hong Kong Chinese women with polycystic ovarian syndrome who were diagnosed according to the hospital's criteria.

MAIN OUTCOME MEASURES

Prevalence of typical features of polycystic ovarian syndrome, including anovulation and hyperandrogenism (with other endocrine causes excluded), polycystic ovarian features on ultrasonography, luteinising hormone predominance, obesity, and insulin resistance.

RESULTS

Almost all (98.9%) patients with polycystic ovarian syndrome presented with anovulation, only 48.9% of them had clinical or biochemical evidence of hyperandrogenism. Typical ultrasound appearances of polycystic ovaries were observed in 86.7% of patients. Luteinising hormone predominance and insulin resistance were demonstrated in 67.8% and 40.7% of the cohort, respectively. Eight-six (95.6%) patients should have also been diagnosed with polycystic ovarian syndrome based on the 2003 Rotterdam new criteria. About 60% of patients who screened positive for insulin resistance had normal fasting serum glucose levels. The same proportion who had full screening for insulin resistance by oral glucose tolerance tests and fasting serum glucose to insulin ratios had discordant results of these two tests.

CONCLUSIONS

The 2003 Rotterdam new diagnostic criteria for polycystic ovarian syndrome are generally applicable to the Hong Kong Chinese population. Early detection of insulin resistance in patients with polycystic ovarian syndrome can be ensured by performing an oral glucose tolerance test combined with measurement of fasting serum glucose to insulin ratio.

The effect of exogenous estradiol treatment on the mRNA expression of vascular endothelial growth factor and its receptors in cultured human oviduct mucosal cells

PURPOSE

To evaluate the responses of cultured oviduct mucosal cells to exogenous estradiol treatment in regulating the mRNA expression of vascular endothelial growth factor (VEGF) and its receptors.

METHODS

The mucosal layer of the ampullary regions of the human oviduct was isolated and cultured with (study groups) or without (control group) the addition of exogenous estradiol in five different concentrations. Semiquantitative reverse-transcriptase-polymerase chain reaction was performed on the oviduct mucosal cells before and after the 6-day culture.

RESULTS

There were no significant differences in the mRNA expression of VEGF and its receptors, both KDR and flt-1, between the five study groups and the control group.

CONCLUSIONS

The mRNA expression of VEGF and its receptors is not altered by exogenous estradiol treatment in cultured oviduct. This helps to explain the mechanism of temporal regulation of VEGF in human oviduct, which reaches the peak level in the peri-ovulatory stage when both the serum estradiol and gonadotropins concentrations are high.

Upregulation of mRNA expression of vascular endothelial growth factor and its receptors by exogenous human chorionic gonadotropin in cultured oviduct mucosal cells

The mucosal cells were isolated from the ampullary regions of 20 human oviducts and cultured with or without hCG in five different concentrations (1-100 ng/mL). As analyzed by the semiquantitative reverse-transcriptase polymerase chain reaction, hCG treatment significantly increased mRNA expression of vascular endothelial growth factor and its receptor flt-1 in the cultured mucosal cells in a dose-dependent manner but had no effect on the expression of another receptor, KDR.

Increased messenger RNA expression of vascular endothelial growth factor and its receptors in the implantation site of the human oviduct with ectopic gestation

OBJECTIVE

To compare the mRNA expression of vascular endothelial growth factor (VEGF) and its receptors (KDR and flt-1) in the implantation and nonimplantation sites of the human oviduct with ectopic gestation.

DESIGN

Prospective observational study.

SETTING

University-based Obstetrics and Gynecology Department.

PATIENT(S)

Ten women undergoing laparoscopic salpingectomy for tubal pregnancy.

INTERVENTION(S)

The mucosal layer was isolated from the implantation and nonimplantation sites of the oviduct tissue with ectopic gestation. Semiquantitative reverse transcriptase-polymerase chain reaction was performed.

MAIN OUTCOME MEASURE(S)

The differences in the mRNA expression of VEGF and its receptors between the implantation and nonimplantation sites of the oviduct tissue.

RESULT(S)

The mRNA expression of VEGF and its receptors, both KDR and flt-1, was significantly higher in the implantation site of the human oviduct with ectopic gestation compared with the nonimplantation site.

CONCLUSION(S)

The results suggest that VEGF may be the angiogenic factor responsible for the implantation and placentation of an ectopic pregnancy in the oviduct.

Revisit of metformin treatment in polycystic ovarian syndrome

Polycystic ovary syndrome (PCOS) is a common endocrinopathy in women; its traditional pharmacological therapy mainly addresses short-term symptom control and does not correct the associated long-term metabolic risks. Recently, there has been increasing evidence that insulin resistance has an important implication in the pathogenesis of PCOS and that insulin-sensitizing drugs are a useful therapeutic approach. Therefore this review aims to discuss the current evidence on the use of metformin, a commonly used insulin-sensitizing agent, in treating both the short-term and the long-term problems of women with PCOS.

Estradiol regulation of oviductin/oviduct-specific glycoprotein messenger ribonucleic acid expression in human oviduct mucosal cells in vitro

OBJECTIVE

To determine whether oviduct mucosal cell culture with exogenous 17beta E(2) supports the continued production of oviductin, a putative embryotrophic protein.

DESIGN

Semiquantitative reverse-transcriptase polymerase chain reaction analysis of oviductin mRNA expression after oviduct mucosal cell culture in the presence of 17beta E(2). Three different culture systems were studied to investigate the response to E(2).

SETTING

University-based obstetrics and gynecology department.

SUBJECTS

Oviduct tissue was obtained from 18 women undergoing laparoscopy for benign gynecologic conditions.

INTERVENTION(S)

The mucosal layer was isolated from the oviduct tissue and exposed to three different culture systems, which contained various concentrations of 17beta E(2), or vehicle-only control.

MAIN OUTCOME MEASURE(S)

The relationship between exposure to 17beta E(2) and expression of oviductin messenger (m)RNA by cultured oviduct mucosal cells.

RESULT(S)

There was a significant increase in oviductin mRNA expression after the addition of 17beta E(2) to the culture system in which the in vivo cell-to-cell and cell-to-basement-membrane contacts of the oviduct had been maintained.

CONCLUSION(S)

Estradiol failed to alter oviductin mRNA expression in oviduct mucosal cells cultured under conditions in which the ciliated mucosal cell phenotype plus the cell-to-cell and cell-to-basement-membrane contacts of the oviduct were lost. However, with a culture system that maintained the cell architecture, E(2) initiated and significantly increased oviductin mRNA expression.

In vivo regulation of mRNA expression of vascular endothelial growth factor receptors (KDR and flt-1) in the human oviduct

OBJECTIVE

To examine the localization of vascular endothelial growth factor receptors (VEGF-R) and the changes in VEGF-R messenger ribonucleic acid (mRNA) expression in various regions of the oviduct from fertile women throughout the ovulatory cycle.

DESIGN

Prospective observational study.

SETTING

University-based obstetrics and gynecology department.

PATIENT(S)

Twenty-two women who underwent laparoscopic tubal sterilization or hysterectomy for a benign gynecological condition.

INTERVENTION(S)

The mucosal layer was isolated from the oviduct tissue. Immunohistochemistry and a semiquantitative reverse-transcriptase-polymerase chain reaction (RT-PCR) was performed.

MAIN OUTCOME MEASURE(S)

Immunohistochemical localization of VEGF-R proteins in oviduct tissue, and the differences of VEGF-R mRNA expression in the various regions of the oviduct and in the various stages of the ovulatory cycle.

RESULT(S)

Immunohistochemical study localized VEGF-R, both KDR and flt-1, in the oviduct luminal epithelium, smooth muscle cells as well as blood vessels within the oviduct. Messenger RNA expression of KDR, but not flt-1, was significantly higher in the ampullary and infundibular regions than in the isthmus. Messenger RNA expression of flt-1, but not KDR, varied significantly in the oviduct along the course of an ovulatory cycle, with the highest level in the periovulatory stage.

CONCLUSION(S)

These results suggest that the two VEGF receptors may have different roles in the oviduct. Our data support a role for KDR in oviduct angiogenesis whereas flt-1 appears to be important in the temporal regulation of oviductal secretion.

Adjuvant low-dose aspirin therapy in poor responders undergoing in vitro fertilization: a prospective, randomized, double-blind, placebo-controlled trial

OBJECTIVE

To evaluate the effect of adjuvant low-dose aspirin on utero-ovarian blood flow and ovarian responsiveness in poor responders undergoing IVF.

DESIGN

Prospective randomized, double-blind, placebo-controlled study.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

Sixty patients classified as poor responders undergoing IVF.

INTERVENTION(S)

Supplementation with low-dose aspirin (80 mg daily) or placebo to a long down-regulation protocol.

MAIN OUTCOME MEASURE(S)

Doppler measurement of intraovarian and uterine pulsatility index was performed before (baseline) and after ovarian stimulation (day of hCG administration). Duration of use and dose of gonadotropins, cycle cancellation rate, number of mature follicles recruited, and oocytes retrieved were also measured.

RESULT(S)

High cancellation rates were found in both groups (33.3% vs. 26.7%, placebo vs. treatment). There were no significant differences in total dose of hMG used (66 vs. 57 hMG, 75 IU ampules), median number of mature follicles recruited (3.5 vs. 3.0), or median number of oocytes retrieved (4 vs. 3). No significant differences were found in either intraovarian or uterine artery pulsatility index measured at baseline or on the day of hCG administration.

CONCLUSION(S)

Supplementation with low-dose aspirin failed to improve either ovarian and uterine blood flow or ovarian responsiveness in poor responders undergoing IVF.

Increased mRNA expression of vascular endothelial growth factor and its receptor (flt-1) in the hydrosalpinx

BACKGROUND

The adverse effects of hydrosalpinx on the outcomes of IVF have been well documented, but the mechanisms of hydrosalpinx fluid formation remain unclear. This study compares the mRNA expression of vascular endothelial growth factor (VEGF) and its receptors (KDR and flt-1) in the hydrosalpinx with that in the healthy oviduct.

METHODS

Oviduct tissue was collected from 10 infertile women with hydrosalpinx and 10 parous women with healthy oviduct. The mRNA expression of VEGF and its receptors in isolated oviduct epithelial cells were analysed using semi-quantitative reverse-transcriptase PCR.

RESULTS

mRNA expression of VEGF and its receptor flt-1 in the hydrosalpinx was significantly higher than that in the healthy oviduct, but no significant difference was demonstrated for the KDR receptor.

CONCLUSIONS

This study supports the notion that VEGF may play an important role in the hydrosalpinx fluid formation, possibly by promoting vascular and epithelial permeability and therefore serum transudation.

Human chorionic gonadotropin and 17-β estradiol regulation of human oviductin/oviduct specific glycoprotein mRNA expression in vitro

OBJECTIVE

To determine whether oviduct mucosal cell culture with exogenous hCG or 17-beta estradiol (E(2)) supports the continued production of oviductin, a putative embryotrophic protein.

DESIGN

Semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of oviductin mRNA expression after oviduct mucosal cell culture in the presence of hCG or 17-beta E(2).

SETTING

University-based Obstetrics and Gynecology Department.

SUBJECT(S)

Ten women undergoing laparoscopy for tubal sterilization or hysterectomy for uterine fibroids.

INTERVENTION(S)

The mucosal layer was isolated from the oviduct tissue, subjected to routine culture conditions with the addition of various concentrations of hCG or 17-beta E(2) or the equivalent vehicle-only control and semiquantitative RT-PCR performed.

MAIN OUTCOME MEASURE(S)

The relationship between exposure to hCG or 17-beta E(2) and expression of oviductin mRNA by cultured oviduct mucosal cells.

RESULT(S)

There was a significant increase in oviductin mRNA expression after the addition of hCG to the culture medium but only in samples that had maintained a baseline level of oviductin expression. Addition of 17-beta E(2) to the culture medium had no significant effect on oviductin mRNA expression.

CONCLUSION(S)

Under standard cell culture conditions, baseline human oviductin mRNA expression is increased by the addition of hCG. This effect is likely to be a secondary or synergistic effect as exogenous hCG failed to restore oviductin mRNA expression in samples where expression was lost after culture. E(2) failed to alter oviductin mRNA expression in oviduct mucosal cells cultured under these conditions.

A study of teratogenicity of hydrosalpinx fluid using a whole rat embryo culture model

BACKGROUND

Hydrosalpinx fluid may be toxic to sperm and early embryo growth. Information concerning the effect of hydrosalpinx fluid on embryo development during organogenesis is lacking.

METHODS

Rat embryos at gestational day 9.5 were cultured for 48 h with 80% rat serum and 20% of either hydrosalpinx fluid (study group) or lactated Ringer's solution (control group). Embryos were scored for growth and development at the end of the culture period.

RESULTS

Hydrosalpinx fluid, collected from 10 patients, was tested for embryotoxicity individually. Median total morphological scores were significantly lower in embryos exposed to hydrosalpinx fluid from three of the 10 patients (43.0 versus 47.0, P = 0.01; 36.0 versus 45.0, P < 0.001; 36.0 versus 46.5, P = 0.003). This was accompanied by a significant reduction in median yolk sac diameter (4.0 versus 5.2 mm, P < 0.001 and 4.0 versus 5.0 mm, P < 0.001) and somite number (17.5 versus 22.5, P < 0.001 and 17.0 versus 21.5, P = 0.008) in the latter two patients.

CONCLUSIONS

Hydrosalpinx fluid in some patients may contain toxin(s) that is potentially teratogenic.

Vascular endothelial growth factor in the human oviduct: localization and regulation of messenger RNA expression in vivo

In this study, we examined the localization of vascular endothelial growth factor (VEGF) and the changes in VEGF mRNA expression in various regions of the oviduct in fertile women throughout the ovulatory cycle. Oviduct tissue was collected from 22 women undergoing laparoscopic tubal sterilization or hysterectomy for a benign gynecological condition. Oviduct sections were divided into isthmus, ampullary, and infundibular regions. Serial cross sections were analyzed for the presence of VEGF by specific immunohistochemical staining. The mucosal layer was isolated, and a semiquantitative reverse transcription polymerase chain reaction was performed. Immunohistochemical study revealed VEGF in the oviduct luminal epithelium, smooth muscle cells, and blood vessels within the oviduct. VEGF mRNA expression in oviduct was the highest during the periovulatory stage, and the expression in the ampullary and infundibular regions was higher than that in the isthmus. There was a significant positive correlation between serum FSH and LH concentrations and VEGF mRNA expression. There was no significant correlation between serum estradiol and progesterone concentrations and VEGF mRNA expression. These results suggest that VEGF in human oviduct may play an important role related the early reproductive events, which occur predominantly in the ampulla during the periovulatory phase when serum FSH and LH concentrations are high.

Psychiatric morbidity amongst infertile Chinese women undergoing treatment with assisted reproductive technology and the impact of treatment failure

This is a prospective study to assess the psychiatric morbidity in Chinese infertile women who underwent treatments with assisted reproductive technology and also the impact of treatment failure. The 30-item General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) were employed before and 3 weeks after the assisted reproductive technology treatment. Data from 372 patients who completed the questionnaires and failed the treatment were analyzed. Before treatment, 33% of the participants scored above the GHQ cutoff, and 8% had a BDI score of 20 or above, signifying moderate to severe depression. Following failed treatment, 43% scored above GHQ cutoff, and 8% had BDI scores 20 or above. The posttreatment GHQ and BDI scores were significantly higher than the corresponding scores at baseline (p < 0.001). About 13% of the participants reported self-harm ideas. The severity of depression following a failed treatment was positively associated with the duration of infertility (p < 0.05), but not with the posttreatment BDI scores, age, education, and number of previous treatment episodes. Our results show that one third of the women who sought infertility treatment had an impaired psychological well-being. Following failed treatment, there was a further deterioration in mental health, and about 10% of the participants were moderately to severely depressed. Proper psychological care and counseling should be an integral part of infertility management among the Chinese population.

Infertility, blood mercury concentrations and dietary seafood consumption: a case-control study

OBJECTIVE

To compare blood mercury concentrations of infertile couples with those of fertile couples in Hong Kong, and to examine the relationship between blood mercury concentrations and seafood consumption.

DESIGN

Case-control study.

SETTING

In vitro fertilisation (IVF) Unit and Antenatal Unit of a university teaching hospital. Sample One hundred fifty-seven infertile couples attending IVF treatment and 26 fertile couples attending antenatal care without known occupational exposure to mercury.

METHODS

Mercury concentrations in whole blood were measured by cold vapour atomic absorption spectrophotometry. A dietitian recorded the quantity of seafood consumption among infertile couples via a food-frequency questionnaire. Blood mercury concentrations and quantity of seafood consumption were compared between infertile and fertile couples.

MAIN OUTCOME MEASURES

Whole blood mercury concentrations, quantity of seafood consumption.

RESULTS

Infertile couples had higher blood mercury concentrations than fertile couples. 'Infertile males with abnormal semen' and 'infertile females with unexplained infertility' also had higher blood mercury concentrations than their fertile counterparts. Blood mercury concentrations were positively correlated with quantity of seafood consumption. Infertile subjects with elevated blood mercury concentrations consumed a larger amount of seafood.

CONCLUSION

Higher blood mercury concentration is associated with male and female infertility. Higher seafood consumption is associated with elevated blood mercury concentrations in our infertile population.

A prospective randomized trial comparing patient-controlled sedation using propofol and alfentanil and physician-administered sedation using diazepam and pethidine during transvaginal ultrasound-guided oocyte retrieval

BACKGROUND

This open label study compared the effectiveness of patient-controlled sedation (PCS), with physician-administered sedation (PAS) during transvaginal ultrasound-guided oocyte retrieval (TUGOR).

METHODS

A total of 106 patients was randomized using a computer model to receive either PCS (n = 51) or PAS (n = 55). Intra-operative sedation and co-operation were measured on a 5-point scale while severity of pain, and doctor and patient satisfaction were assessed using a 100 mm visual analogue scale. Number of oocytes retrieved and fertilization, cleavage and clinical pregnancy rates were also recorded.

RESULTS

Levels of sedation and co-operation were similar between groups. The pain score was higher in the PCS group during (mean +/- SD, 53 +/- 23 versus 35 +/- 24; P < 0.01) and 2 h after the procedure (29 +/- 27 versus 17 +/- 22; P < 0.05). Doctors were less satisfied with PCS than PAS (62 +/- 25 versus 71 +/- 26; P < 0.05) while patients were highly satisfied with both methods (76 +/- 23 versus 74 +/- 21; not significant). There were no oversedation or peri-operative complications. Fertility outcomes were similar. Patients tended to prefer PCS when given the choice of sedation method.

CONCLUSION

Although PCS provides less analgesia then PAS during TUGOR, it is safe, satisfactory and accepted by patients.

Follicular fluid and serum concentrations of myo-inositol in patients undergoing IVF: relationship with oocyte quality

BACKGROUND

The follicular microenvironment is an important determinant of oocyte development. The aim of this study was to examine whether the myo-inositol (MI) content in human follicular fluid (FF) was associated with better oocyte quality.

METHODS

A total of 53 patients treated with IVF was recruited to a prospective observational study. FF and serum samples collected were divided into two groups: group A consisted of FF associated with matured and fertilized oocytes, whilst group B was from follicles with immature and unfertilized oocytes.

RESULTS

Patient's age, total ampoules of HMG used, days of stimulation, basal levels of FSH, estradiol (E(2)) levels on the day of HCG, and serum MI content were not significantly different between the two groups. FF volume and its MI content were significantly higher in group A compared with group B (P < 0.05). The levels of MI in FF were positively correlated with the amount of E(2) in their corresponding FF samples and also correlated with embryo quality.

CONCLUSIONS

We propose that higher concentrations of MI and E(2) in human FF appear to play a role in follicular maturity and provide a marker of good quality oocytes.

Intrauterine adhesions after conservative and surgical management of spontaneous abortion

STUDY OBJECTIVE

To determine the frequency of intrauterine adhesions (IUA) after conservative management, medical evacuation, and surgical evacuation for spontaneous abortion.

DESIGN

Prospective follow-up study (Canadian Task Force classification II-2).

SETTING

Gynecology unit in a teaching hospital.

PATIENTS

Eighty-two women who had been treated with conservative management, medical evacuation, or surgical evacuation of retained products of conception after spontaneous abortions in a randomized, controlled trial.

MEASUREMENTS AND MAIN RESULTS

Hysteroscopic diagnosis of IUA 6 months after initial treatment was the primary outcome measure. No cases of IUA were found in patients managed conservatively or by medical evacuation, whereas two cases (7.7%) of filmy IUA were detected in those managed by surgical evacuation. There was no statistical significant difference in the rate of self-reported reduced menstrual flow 6 months after initial treatment by any method.

CONCLUSION

The prevalence of IUA was low after each modality of treatment for spontaneous abortion. Conservative management and medical evacuation are both acceptable alternatives to standard surgical evacuation.

Effects of the intensity of downregulation on outcome of in vitro fertilization and embryo transfer

Gonadotropin releasing hormone agonists (GnRHa) are commonly used during in vitro fertilization and embryo transfer (IVF/ET) treatment cycles to downregulate the hypothalamic-pituitary-ovarian axis prior to ovarian stimulation with gonadotropins. It has been suggested that profound downregulation may have an adverse effect on IVF/ET outcome. The aim of this study was to examine the relationship between the degree of downregulation and IVF/ET outcome. A retrospective analysis was performed on 151 IVF/ET cycles conducted over a six month period. Intensity of downregulation was assessed using measurements of serum concentrations of luteinizing hormone (LH) and estradiol (E2) made at the end of a two week downregulation period. There was no correlation between serum concentration of LH (whether used alone or in combination with E2) and IVF/ET pregnancy rates. However, those subjects who were more suppressed according to the E2 concentration (< 148 pmol/l, [median]) required significantly more gonadotropins (3306 IU versus 2863 IU, p < 0.05) and took longer for follicles to reach maturity (10.9 days versus 9.7 days, p < 0.05). They also had a lower pregnancy rate per embryo transfer (10.4% versus 28.6%, p < 0.05) compared with those having a higher basal E2 concentration. We conclude from this study that the basal serum E2 concentration rather than the LH concentration is a more sensitive indicator of the intensity of downregulation by GnRHa and it may be a better predictor of IVF outcome.

Human oviductin mRNA expression is not maintained in oviduct mucosal cell culture

OBJECTIVE

To determine whether oviduct mucosal cell culture supports the continued production of oviductin, a putative embryotrophic protein.

DESIGN

Semiquantitative reverse-transcriptase polymerase chain reaction (RT-PCR) analysis of oviductin messenger RNA (mRNA) expression after oviduct mucosal cell culture.

SETTING

University-based obstetrics and gynecology department.

PATIENT(S)

Ten women undergoing laparoscopy for tubal sterilization or hysterectomy for uterine fibroids.

INTERVENTION(S)

The mucosal layer was isolated from the oviduct tissue and subjected to routine culture conditions; semiquantitative RT-PCR was performed.

MAIN OUTCOME MEASURE(S)

The relationship between duration of cell culture and expression of oviductin mRNA.

RESULT(S)

There was a significant reduction in oviductin mRNA expression after 3 days in culture, with a complete loss after 6 days in 70% of the samples and after 12 days in the remaining 30%. CONLCUSION(S): This is the first study to investigate whether oviductin mRNA continues to be expressed in cultured human oviduct mucosal cells. Our results suggest that oviduct mucosal cells lose their ability to produce oviductin after short-term culture. This method of culture does not appear to be appropriate for a coculture system reliant upon oviductal secretion of oviductin.

A comparison of the psychologic impact and client satisfaction of surgical treatment with medical treatment of spontaneous abortion: a randomized controlled trial

OBJECTIVE

The purpose of this study was to compare the psychologic impact and client satisfaction of routine surgical evacuation of the uterus with medical evacuation in cases of spontaneous abortion.

STUDY DESIGN

This was a prospective, randomized controlled trial. Two hundred eighteen women who were admitted to a university teaching hospital after spontaneous abortion and who consented to the study were randomized to routine surgical evacuation or medical evacuation of the uterus with the use of misoprostol. General psychologic well-being, level of depression, fatigue symptoms, psychiatric morbidity, social functioning, client satisfaction, and acceptance were measured in the 2 groups.

RESULTS

The 2 groups did not differ in any of the measured psychological outcomes. Significantly more participants who experienced successful evacuation of the uterus with the misoprostol protocol would choose the same mode of treatment if they were able to choose again. However, participants for whom the medical treatment failed to evacuate the uterus and subsequent surgical evacuation was required are significantly less satisfied with the treatment.

CONCLUSION

Medical treatment of spontaneous abortion with misoprostol is psychologically safe and more compatible with the ethnomedical beliefs of our Chinese participants. Client satisfaction and acceptance should be taken into consideration in the evaluation of treatment outcomes.

Regulation of human oviductin mRNA expression in vivo

OBJECTIVE

To examine changes in oviductin mRNA expression in oviductal mucosal tissue from fertile women throughout an ovulatory cycle.

DESIGN

Semiquantitative reverse-transcriptase-polymerase chain reaction (RT-PCR) analysis of oviductin mRNA.

SETTING

University-based obstetrics and gynecology department.

SUBJECT(S)

Twenty women undergoing laparoscopy for tubal sterilization or hysterectomy for uterine fibroids.

INTERVENTION(S)

The mucosal layer was isolated from the oviduct tissue, and semiquantitative RT-PCR was performed.

MAIN OUTCOME MEASURE(S)

The relationship between serum estradiol, luteinizing hormone, and progesterone concentrations and the expression of oviductin mRNA.

RESULT(S)

There was a significant positive correlation between serum estradiol and luteinizing hormone concentrations and oviductin mRNA expression. There was a significant inverse correlation between serum progesterone concentrations and oviductin mRNA expression.

CONCLUSION(S)

Little is known about the regulation of human oviductin. This study was the first to examine the relationship between oviductin mRNA expression and serum estradiol and luteinizing hormone and progesterone concentrations in fertile women. Estradiol and luteinizing hormone both have a stimulatory effect on oviductin mRNA in humans, however, it is difficult to determine whether the effects are independent of one another, as the luteinizing hormone surge is dependent on the estradiol increase. Progesterone shows a clear inhibitory effect on oviductin mRNA.

Dose-finding study for the use of long-acting gonadotrophin-releasing hormone analogues prior to ovarian stimulation for IVF

Gonadotrophin-releasing hormone (GnRH) analogues improve the outcome of treatment with IVF by increasing the number and quality of oocytes retrieved and by reducing cycle cancellation rates. Whilst short-acting GnRH analogues are most commonly used, depot preparations are now available that are more convenient for patient use. Some studies have reported that pregnancy rates with depot GnRH analogues are similar to those of short-acting preparations, but others have suggested that the more profound down-regulation seen with depot GnRH analogues results in inferior embryo quality. The purpose of this study was to determine whether a lower than conventional dose of a depot GnRH analogue may be more appropriate for use in ovarian stimulation prior to IVF. Sixty patients were randomized to receive either 3.75 mg (conventional dose) or 1.87 mg (low dose) triptorelin prior to ovarian stimulation for IVF. Suppression was measured using serum concentrations of LH measured 2 and 3 weeks after the administration of the GnRH analogues, the dose of gonadotrophin used and the time to resumption of menses. Mean concentrations of LH were 2.2 +/- 1.0 and 1.1 +/- 0.6 IU/l in the conventional dose group and 3.5 +/- 5.5 and 2.7 +/- 1.9 IU/l in the low dose group (P < 0.05 at 2 and 3 weeks). There were no significant differences between the doses of gonadotrophins used, the number of oocytes and embryos available and the time to resumption of menses, nor in the pregnancy rates. Although the degree of suppression as measured biochemically was more profound with the conventional dose, this did not affect the IVF outcome. The use of a lower dose therefore appears to be equally effective and could contribute to a reduction in the cost of treatment.

The effects of follicular fluid and platelet-activating factor on motion characteristics of poor-quality cryopreserved human sperm

PURPOSE

To evaluate the effects of follicular fluid and platelet-activating factor on sperm motion characteristics of cryopreserved oligospermic and normospermic samples.

METHODS

Sperm motion characteristics were evaluated prior to cryopreservation, immediately after thawing and following incubation in human tubal fluid, follicular fluid, or 1-microM platelet-activating factor cultures. Sixteen oligospermic samples and 20 normospermic samples were examined. Sperm motion characteristics were analyzed manually according to WHO criteria (1999) and also with an automated videomicrography system.

RESULT(S)

Incubation in follicular fluid increased overall motility and the percentage of sperm with fast progressive motility in normospermic but not oligospermic samples. Incubation with platelet-activating factor increased overall motility and the percentage of sperm showing nonprogressive motility in both oligospermic and normospermic samples.

CONCLUSION(S)

The stimulatory effects of culture in follicular fluid as seen in normospermic samples do not show a significant benefit in oligospermic cryopreserved samples. Platelet-activating factor and follicular fluid increase motility via different mechanisms. Incubation of oligospermic cryopreserved sperm with PAF increases the number of motile sperm, thereby enabling easier identification of viable sperm for intracytoplasmic sperm injection in samples with severe asthenozoospermia.

Evaluation of the accuracy of transvaginal sonography for the assessment of retained products of conception after spontaneous abortion

Transvaginal sonography (TVS) was used to assess uterine contents in 100 consecutive subjects presenting with a diagnosis of spontaneous abortion. TVS assessments were correlated with findings at subsequent evacuation of retained products of conception (ERPC). There was a strong correlation between the weight of the surgical specimen at ERPC with both the sagittal (r = 0.76; p < 0.05) and transverse (r = 0.73; p < 0.05) plane area measurements of the uterine cavity. Combining the 2 sonographic measurements increased the correlation to r = 0.81 (p < 0.05). Fifteen of 25 subjects who had been categorised to have an 'empty' uterus had less than 5 g of tissue removed and the other 10 subjects less than 10 g of tissue. In 20 of these 25 cases, the surgeon described the amount of curettings as 'small or non-significant'. TVS can accurately identify those women who do not have a significant amount of residual uterine tissue following spontaneous abortion.

Patient selection for assisted reproductive technology treatments

Assisted reproductive technologies refer to procedures in which the oocyte is handled or manipulated in vitro before replacement, either as an oocyte or an embryo. Because of rapid advances in this area, infertile couples may seek direct referral for assisted reproductive treatments, instead of trying simpler measures such as ovulation induction and intrauterine insemination. It is important to establish whether these conventional infertility treatments are appropriate, as such treatments are generally safer, less stressful, and more affordable. On the other hand, subjecting infertile couples to unnecessary delay by offering inappropriate treatments-for example, ovulation induction for tubal infertility or intrauterine insemination for severe male-factor infertility-would reduce the overall chance of success because of the age-related decline in female fecundity. The choice of infertility treatments thus depends on a balance of factors: the chance of pregnancy without treatment; the chance with simpler and safer, but less successful, infertility treatments; or the chance with the more complex and costly, but more effective, assisted reproductive treatments. The factors that should be taken into consideration include the age of the woman, the duration of infertility, the causes of infertility, the availability and cost of alternative treatments, and-most importantly-the acceptability.

Spontaneous abortion: a randomized, controlled trial comparing surgical evacuation with conservative management using misoprostol

OBJECTIVE

To compare the efficacy of surgical evacuation of the uterus with medical evacuation using misoprostol in cases of spontaneous abortion.

DESIGN

A prospective, randomized, controlled trial.

SETTING

A university teaching hospital.

PATIENT(S)

Six hundred thirty-five women who aborted spontaneously and who consented to pretreatment randomization.

INTERVENTION(S)

Routine surgical evacuation or medical evacuation of the uterus using misoprostol.

MAIN OUTCOME MEASURE(S)

Immediate, short-term (2-3 weeks), and medium-term (6 months) medical complications.

RESULT(S)

There was a significantly lower incidence of immediate and short-term complications in the group treated with misoprostol compared with the surgically treated group. There were also fewer major complications in the 6 months after treatment in the medically treated group. Approximately 50% of the medically treated group subsequently required surgical evacuation, and these subjects required significantly more analgesia.

CONCLUSION(S)

Treatment with misoprostol can reduce the demand for surgical evacuation in cases of spontaneous abortion, and its use is associated with fewer medical complications.

Anterior cruciate ligament injury: fast spin-echo MR imaging with arthroscopic correlation in 217 examinations

OBJECTIVE

Our objective was to evaluate the accuracy of MR imaging strategy that uses primarily fast spin-echo sequences for the diagnosis of anterior cruciate ligament tears.

MATERIALS AND METHODS

The original clinical interpretations of MR images of 217 examinations of the knee joint were correlated with subsequent arthroscopic results. Each MR examination included a double-echo fast spin-echo sequence as the only imaging sequence in the sagittal plane. Subsequent discordant MR and arthroscopic examinations were then subjected to reanalysis by two observers who were unaware of arthroscopic results to determine if misinterpretations were observer or image dependent. Two hundred sixteen patients who underwent MR imaging for suspected internal derangement of the knee subsequently underwent arthroscopic surgery. Two patients had both knees evaluated. One patient was excluded because he was referred for evaluation for osteomyelitis, not internal derangement. This yielded a total number of 217 MR examinations for suspected internal derangement of the knee.

RESULTS

For 56 arthroscopically proven tears, the sensitivity of MR imaging was 96%. The specificity was 98%, yielding an overall accuracy rate of 98%. The positive and negative predictive values were 95% and 99%, respectively. These values are within the ranges of previously reported MR imaging strategies using conventional spin-echo sequences.

CONCLUSION

Fast spin-echo MR imaging of the knee can be an alternative to conventional spin-echo imaging for the detection of anterior cruciate ligament tears.

Acute effects of a surgical menopause on serum concentrations of lipoprotein(a)

OBJECTIVE

The aim of this study was to investigate acute changes in serum concentrations of lipoprotein(a) and other atherogenic lipids and lipoproteins after a surgical menopause.

METHODS

A total of 100 premenopausal Chinese women who were booked for hysterectomy for benign gynecological disorders were recruited. They study group comprised 40 subjects undergoing hysterectomy as well as bilateral oophorectomy. The control group consisted of 60 subjects undergoing hysterectomy with conservation of the ovaries. Complete data were available from 30 of the 40 subjects in the study group and from 44 of the 60 controls. Serum concentrations of lipoprotein(a) and other atherogenic lipids and lipoproteins were measured before surgery and these measurements were repeated 3 days, 8 weeks and 6 months postoperatively. Those study patients who received hormone replacement therapy and control patients who became menopausal, according to biochemical criteria, during the study period were excluded from analysis.

RESULTS

Three days after surgery, there was a significant increase in the mean lipoprotein(a) concentration in the control group from 19.1 to 23.0 mg/dl (p < 0.01), but there was no significant change in the study group. There were no significant changes from baseline in the mean lipoprotein(a) concentration in either group 8 weeks or 6 months after surgery. There was a significant increase in the mean concentration of total cholesterol in the study group 8 weeks after surgery from 5.08 to 5.45 mmol/l (p < 0.01), in low density lipoprotein cholesterol from 3.22 to 3.49 mmol/l (p < 0.01), and in apolipoprotein B from 95.6 to 103.0 mg/dl (p < 0.05). However, the mean concentrations 6 months after surgery were not significantly different from baseline levels. The mean concentrations of high density lipoprotein cholesterol, apolipoprotein A-1 and triglycerides also did not differ significantly from baseline in the study group, either 8 weeks or 6 months after surgery.

CONCLUSIONS

These results suggest that any increase in concentrations of lipoprotein(a), and other atherogenic lipids and lipoproteins which occur after the menopause, develops relatively slowly. The changes in concentrations which occurred within 8 weeks of surgery were probably an acute-phase reaction after surgery rather than a response to a decreasing estradiol concentration.

Spontaneous abortion: short-term complications following either conservative or surgical management

Spontaneous abortion is a common gynaecological condition. It is a commonly held belief that medical morbidity associated with this condition is low and that routine treatment should be surgical evacuation of the uterus. This study was performed to study the short-term complications of spontaneous abortion and its management. Transvaginal sonography (TVS) was used to determine whether retained products of conception (POCs) were visible inside the uterus in women presenting with spontaneous abortion. If tissue was present, surgical evacuation of retained products of conception (ERPC) was performed. If the uterus was empty, the patients were managed expectantly. Four hundred and seventy women were treated with ERPC and 297 were managed expectantly. The complication rate was 3.0% in those managed expectantly compared with 5.8% for those treated by ERPC. Subjects with no POCs on TVS can therefore be managed expectantly without increasing the risk of morbidity associated with this condition.

Compliance with hormone replacement therapy in Chinese women in Hong Kong

Compliance with hormone replacement therapy (HRT) has been extensively studied in western countries. However, there is little data concerning women in Asian countries. A retrospective study was performed to determine compliance in a group of Hong Kong Chinese women who commenced HRT over a 2 year period. Two years after the commencement of HRT, 68.3% were still taking HRT, although not always in the original formulation. The highest drop out rate occurred during the first 6 months. Factors which were associated with a higher degree of compliance were young age at menopause and at the time of initial consultation and the use of unopposed HRT. A number of significant medical problems were identified during the 2 years of follow up which may have remained otherwise undetected. Compliance with HRT appears to be comparable to that reported in other western specialist centres. Nearly 9% of women who stopped HRT did so because other doctors told them that they did need the treatment and another 6.5% because of the fear of breast cancer.