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Congenital cystic adenomatoid malformation (CCAM) is a rare pulmonary malformation resulting from excessive overgrowth of the terminal bronchioles. We present two CCAM case studies: type I (macrocystic) and type III (microcystic), diagnosed by antenatal ultrasonography at 31 and 21 weeks' gestation, respectively. In the former, multiple dilated cystic masses in the fetal left lung, with polyhydramnios, were identified during the antepartum examination. A postnatal thoracotomy with lobectomy was performed due to persistent cyanosis and resulted in a good outcome. In the latter case, an echogenic mass with multiple cysts in the fetal right lung was detected by prenatal sonography. The parents decided to terminate the pregnancy after prenatal counseling.

Background: Ovarian cancer is a well-known disease with a poor prognosis. Due to the relatively small number of cases in Taiwan, the outcome and prognostic factors of patients with primary epithelial ovarian carcinoma are unknown., Methods: We retrospectively studied patients with proven surgical and pathologic (Federation Internationale de Gynecologie et d'Obstetrique) FIGO IIIC primary epithelial ovarian carcinoma. All patients underwent standard staging surgery, including washing cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, retroperitoneal lymphadenectomy, infracolic omentectomy and excisional biopsy of all suspicious lesions followed by adjuvant chemotherapy with four to 12 courses of cyclophosphamide, epirubicin and cisplatin (CEP) or cyclophosphamide, adriamycin and cisplatin (CAP) intravenously, every three weeks. To avoid the coeffects of chemotherapy and surgical procedures upon the outcome, patients who received paclitaxel-based regimens or underwent incomplete surgery were excluded. Ninety-eight patients from 1990 to 1996 were identified., Results: The mean follow-up time was 28.7 months, ranging from 5.4 months to 105.9 months. The cumulative five-year disease-free survival rate for all patients was 31.6%. Optimal debulking surgery was completed in 41.8% of patients, which contributed to long-term patient survival (54% vs 16%, p < 0.0001), compared to patients without optimal debulking surgery. Optimal debulking surgery was the only statistically significant independent prognostic factor for five-year disease-free survival using multivariate analysis., Conclusions: To improve survival of patients with FIGO stage IIIC epithelial ovarian carcinoma, optimal debulking surgery should be performed as the initial form of surgical intervention.

Acute abdomen is a challenge to first-line physicians because of frequently missed diagnoses and potential follow-on legal problems. Improving the management of these patients is of paramount importance, not only for saving lives, but also for reducing untoward problems associated with improper management. We present a case of a patient with acute abdomen due to intraperitoneal hemorrhage secondary to rupture of an ovarian tumor. Following emergency surgery, the patient was diagnosed with metastatic ovarian carcinoma. Because of improper preparation of the gastrointestinal tract, the patient underwent repeat exploratory laparotomy for colon carcinoma. Although this situation did not affect the outcome of the patient in this case, we are concerned that the patient did not benefit from a single operation, with primary complete excision of the tumor plus a colostomy. The outcome of patients with pelvic malignancy, especially those with ovarian carcinoma, might be better if initial surgery achieved optimal tumor debulking. This is possible with good preoperative planning and preparation. We emphasize the importance of preoperative preparation in spite of urgently needed care. Furthermore, every first-line physician should communicate the possibility of malignancy to patients and their families.

Background: Because of the rarity of primary fallopian tube adenocarcinoma (PFTA), the outcome of advanced primary fallopian tube carcinoma has not been fully evaluated, especially in Taiwan., Methods: We retrospectively studied patients with proven surgicopathologic stage III PFTA. Thirteen patients from 1965 to 1995 were identified. All patients received standard staging surgery including washing cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, retroperitoneal lymphadenectomy, infracolic omentectomy and excisional biopsy of all suspicious lesions. This was followed by adjuvant chemotherapy with four to eight courses of CAP or CEP (cyclophosphamide 500 mg/m2, adriamycin 50 mg/m2, or epirubicin 50 mg/m2, and cisplatin 50 mg/m2 intravenously, every 3 weeks) regimen., Results: The accumulative disease-free survival rate was 15%. The incidence of retroperitoneal lymph node metastases was high, up to 69%, and the incidence of para-aortic lymph node metastases was 62%. Eighty-five percent of the cases were poorly differentiated carcinoma. Optimal debulking surgery was completed in 62% of patients, contributing to long-term patient survival (25% vs 0%), compared with those without optimal debulking surgery., Conclusions: The prognosis of stage III PFTA in our study was poor. Careful lymph node dissection in the retroperitoneal space including the para-aortic area is required. Optimal debulking surgery plus postoperative adjuvant chemotherapy appears to be the only option for enhancing long-term disease-free survival.

Carcinoma of the cervix spreading to the paracervical lymphatics is a common phenomenon followed by involvement of the para-aortic lymph nodes and subsequent distant metastases. The most common extranodal metastases sites are the lungs, followed by the liver and bones. The heart is an extremely rare metastatic target for carcinoma of the cervix. Furthermore, the majority of cardiac metastases involve the pericardium and endocardium and are particularly rare. We present the case of a 56-year-old woman with recurrent squamous cell carcinoma of the cervix who died after aggressive multimodality treatment including concurrent chemoradiotherapy and surgical intervention. The patient died suddenly and the autopsy showed disseminated carcinomatosis with portal vein, hepatic vein, inferior vena cava and right ventricular tumor emboli.

Ovarian carcinoma commonly occurs in postmenopausal women and often presents with an insidious course. Acute abdomen is rarely an initial symptom. When these patients present with abdominal discomfort, the disease has already spread throughout the peritoneal cavity. We present a case of mucinous cystadenocarcinoma in a young woman who presented with acute abdomen and intra-abdominal bleeding. This 24-year-old woman was previously diagnosed with a ruptured left ovarian cystic tumor at a primary clinic. She underwent emergency exploratory laparotomy, followed by unilateral salpingo-oophorectomy at the clinic. No thorough examination of the peritoneal cavity was done during surgery. The diagnosis of mucinous cystadenocarcinoma was accidentally over-looked until one month later when she returned for routine follow-up. Upon referral to our clinic, the patient underwent a repeat laparotomy. The surgicopathologic diagnosis was intraperitoneal carcinomatosis stage IIIC that could not be excised completely, even though rigorous staging surgery including washing cytology, total abdominal hysterectomy, salpingo-oophorectomy, retroperitoneal lymphadenectomy, appendectomy, infracolic omentectomy and excision of any suspicious and removable lesions were performed. This case alerts us to consider the possibility of ovarian malignancy when a young woman presents with an acute abdomen secondary to ruptured ovarian cystic tumor and intraperitoneal hemorrhage. Careful preoperative preparation and thorough intrasurgical examination of the peritoneal cavity along with a prompt pathologic diagnosis of suspicious lesions will prevent missed diagnoses.

Urethral diverticula are rarely encountered in the gynecologic out-patient setting. However, this condition probably occurs more frequently than it is diagnosed. The patient frequently notes signs of lower urinary tract irritation. Urinary dribbling accompanied with dyspareunia and dysuria constitutes a classic triad for urethral diverticula. Symptoms of chronic pelvic pain only occur in a minority of patients. We report a case of urethral diverticulum presenting chiefly with chronic pelvic pain. The patient underwent multiple investigative operations before a correct diagnosis was made. When confronted with a patient presenting with chronic pelvic pain, a gynecologist should retain a high index of suspicion for a urethral diverticulum in addition to other gynecologic conditions.

A solitary inguinal lymph node metastasis from a poorly differentiated adenosquamous cell carcinoma of unknown origin in a 52-year-old female is described. The patient was reported to have had a 2-cm palpable mass in the left inguinal area for three years. She had made regular annual clinic visits for Pap smears since the age of 45 years. Her last visit was eight months prior to a complaint of progressive abdominal distention and dull pain of three months' duration. Physical examination showed a huge pelvic mass, and ultrasound and magnetic resonance imaging of the abdomen showed a 12-cm complex solid mass on the left ovary. The patient underwent a complete excisional biopsy of the left inguinal lymph node. Frozen section pathology revealed a poorly differentiated adenosquamous cell carcinoma. Exploratory laparotomy immediately followed pathologic confirmation of malignancy of the left inguinal lymph node. Complete surgical staging including abdominal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, retroperitoneal lymph node sampling and excisional biopsy was performed for all suspicious lesions. Stage IIIC malignant mixed mesodermal tumor (MMMT) was diagnosed due to positive left inguinal lymph node metastasis. However, the retroperitoneal lymph node and intra-abdominal cavity did not show spread of the tumors, except those confined to the left ovary with adhesion to the cul-de-sac, and sole lymph node metastasis in a left inguinal lymph node. Although we could not prove that the left inguinal lymph node metastasis had been present for the three years that it was palpable without histologic confirmation, we believe that any enlarged inguinal lymph node might be the first hint of underlying malignancy in the pelvic area, lower extremities or perineal area. In cases of a poorly differentiated carcinoma of inguinal lymph nodes of unknown origin, the abdomen should be carefully evaluated.

Because of the rarity and insidious onset of primary adenocarcinoma of the fallopian tube, early diagnosis is very difficult. Primary fallopian tube carcinoma is also rarely diagnosed preoperatively. This report reviews the value of magnetic resonance imaging (MRI) in aiding the detection of early-stage primary fallopian tube carcinoma in a 48-year-old female. The diagnosis was based on clinical suspicion, elevated CA-125 and MRI. MRI demonstrated the tumor as an area of solid masses with marked enhancement after gadolinium-diethylenetetraaminepentaacetic acid (Gd-DTPA) administration. Primary fallopian tube carcinoma was confirmed by pathologic examination. We hope that, with improvements in imaging, early diagnosis of such a malignant disease could become routinely possible in the future.

Background: There are few reports on maternal cerebral circulation during pregnancy. Using the hypothesis that cerebral blood flow resistance decreases progressively with advancing gestational age (GA) as a consequence of estrogenic effects on the vascular system during pregnancy, we calculated the pulsatility index (PI) and the mean velocity (MV) of the maternal right internal carotid artery (ICA) in order to build fitted reference centiles., Methods: A total of 315 pregnant women with a single fetus were studied at 20-42 weeks' gestation. The patients had uncomplicated singleton pregnancies and were without any known fetal or maternal risk factors. Duplex color ultrasound with a pulsed Doppler scanner (7.5 MHz) was used to determine the PI and MV of the maternal ICA., Results: Among the 315 healthy pregnant women, the PI of maternal ICA decreased progressively with advancing GA, PI50th = Exp (0.3124-0.0084 x GA), (p = 0.0003), during the second half of pregnancy. The predicted 50th percentile PI values of the ICA decreased from 1.117 (5th% = 0.755, 95th% = 1.654) at 24 weeks' gestation to 0.917 (5th% = 0.659, 95th% = 1.448) at 40 weeks' gestation. The MV of the maternal ICA also decreased progressively with advancing GA, MV50th = Exp (3.855-0.0093 x GA), (p = 0.0005), during the second half of pregnancy. The predicted 50th percentile MV values in the ICA decreased from 37.811 cm/sec (5th% = 24.177 cm/sec, 95th% = 59.138 cm/sec) at 24 weeks' gestation to 32.591 cm/sec (5th% = 20.818 cm/sec, 95th% = 51.021 cm/sec) at 40 weeks' gestation., Conclusions: Both the PI and MV of the maternal ICA decreased with GA during the second half of normal pregnancy as a result of intracerebral vessel dilatation.

Adenomyosis of the uterus is a serious problem for women of reproductive age because of its possible consequence of infertility. We present the case of a woman who had adenomyosis of the uterus, a successful spontaneous pregnancy, and delayed and tenacious postpartum hemorrhage that did not respond to conservative treatment. The 26-year-old woman, gravida 1, para 1, suffered from fulminating vaginal bleeding and associated shock 20 days after the delivery of a 3,450-g female by Cesarean section. Conservative treatment included uterine compression and massage, blood transfusion, intravenous administration of high-dosage estrogen, oxytocin and sulprostone (prostaglandin E analogue), and gauze packing from the vagina into the uterine cavity. Despite treatment, the patient went into shock due to persistent vaginal bleeding. Emergency exploratoric assessment laparotomy was performed, followed by a stotal hysterectomy. Pathology revealed extensive adenomyosis of the uterus without other significant abnormality. The potential dangers of adenomyosis in pregnancy should not be overlooked when patients seek treatment for infertility.

Background: This study was performed in order to assess the surgical effects and characteristics of ovarian tumors during pregnancy and analyze their prognosis., Methods: Between 1982 and 1993, 121 patients who had undergone ovarian surgery during pregnancy or puerperium were reviewed at the Veterans General Hospital-Taipei. These patients were analyzed with particular emphasis on the length of gestation at the time of surgery, complications related to the stage of pregnancy, surgical and pathologic findings and the outcome of pregnancy., Results: Ovarian tumors were commonly detected during the second trimester (54.5%) and most of them (79.3%) were asymptomatic. The pathologic review found 38 patients (31.4%) with benign teratoma, 16 patients (13.1%) with corpus luteum and four patients (3.3%) with malignancy. There was a significant difference between emergent ovarian surgery and elective ovarian surgery in the spontaneous fetal wastage rate (14.1% vs 1%, p = 0.009). Compared with elective surgery, cases necessitating oophorectomy, with or without salpingectomy, increased significantly during emergency surgery (57% vs 36%, p = 0.03). All ovarian surgeries performed before a gestational age of seven weeks resulted in spontaneous fetal wastage., Conclusions: Although the majority of the ovarian tumors detected during pregnancy were benign, emergency laparotomy was sometimes required, which led to an increase in the risk of a fetal wastage. Preconception counseling should be emphasized because early removal of non-functional ovarian tumor before conception, especially teratoma, would decrease the incidence of ovarian surgery during pregnancy. Furthermore, elective and well-prepared surgical intervention appears to be a crucial factor for favorable pregnancy outcome.

Background: Although recent studies have shown that HIV (human immunodeficiency virus) can attach to sperm, the mechanism by which it does this is not yet understood. It has been shown that CD4 receptors on T4 cells are responsible for the binding of gp120 (glycoprotein 120) to HIV; however, the existence of CD4 receptors on sperm is controversial. The V3 peptide is part of gp120 and crucial for the syncytium formation by CD4 receptors. In this study we used an anti-CD4 antibody to block V3 peptide-induced sperm head agglutination in an attempt to gain a further understanding of the mechanism of HIV attachment to sperm., Methods: Ten semen samples from 10 healthy men were studied. A sperm head fixation method (SHFM) was used to evaluate the blocking effect of anti-CD4 antibody (Q4120) of V3 peptide-induced sperm head agglutination in phosphate-buffered saline solution., Results: While the sperm swam out of the micropipette, as occurs in SHFM, the V3 peptide induced an average of 53.2 +/- 10.8 (mean +/- SEM) head-to-head bound sperm (in the 10 semen samples. The sperm that had been preincubated with anti-CD4 antibody induced an average of 54.1 +/- 11.6 head-to-head bound sperm. There was no significant difference found between sperm that had been preincubated or not preincubated with anti-CD4 antibody, in terms of sperm head agglutination., Conclusions: The anti-CD4 antibody can block the binding of gp120 and CD4 positive T cells in a low concentration, but it did not block V3 peptide-induced sperm head agglutination. Therefore, V3 peptide-induced sperm head agglutination may not occur through a CD4 receptor.

Background: Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common genetic diseases of human. Traditionally, ADPKD is diagnosed by ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI) of kidneys for the presence of renal cysts. Individuals who carry the defective gene but have not yet developed cysts in kidney may not be diagnosed. Genetic analysis reveals it to be caused mostly by a single-gene disorder of a genetic locus, designated PKD1. Recently, the genetic locus involving PKD1 has been identified on chromosome 16p13.3, and has been cloned and completely sequenced., Methods: A pair of primers, KG8-CA, located between D16S84 and D16S125, was selected and synthesized for the polymerase chain reaction (PCR) to identify individuals who may carry the defective locus. The sequence of KG8-CA primers, was 5'-CTCCCAGGGTGGAGGAAGGTG-3' and 5'-GCAGGCACAGCCAGCTCCGAG-3'. PCR products were analyzed in denaturing condition, using gel containing 8% acrylamide and 7M urea. Autoradiography was carried out to interpret the results., Results: Four Chinese families with history of ADPKD showed different DNA patterns in individuals with ADPKD and in normal individuals. Among the members in four families with history of ADPKD, every individual shared a common DNA band, suggesting that this band was derived from normal PKD1 allele. On the other hand, individuals diagnosed to have ADPKD showed one or two additional DNA bands which migrated differently from the common DNA band and should therefore be derived from defective ADPKD allele. Previous studies have shown that the ADPKD allele is highly polymorphic, as was evident in these family studies., Conclusions: Among the members from these four families, some were clinically normal and had DNA pattern that was typical to patients with ADPKD. These individuals might carry the defective PKD1 allele but have not yet developed the ADPKD symptoms. Therefore, the method described in this study has diagnostic values for pre-symptomatic individuals as well as for patients already diagnosed with ADPKD.

Background: Blood flow resistance of the subplacental spiral arteries in second-trimester pregnancies has not been previously reported. A reference range of blood flow resistance of the subplacental spiral arteries at 13-25 gestational weeks was designed in the hope the reference data could provide a basis for Doppler studies of pathologic disorders in second-trimester pregnancies., Methods: A cross-sectional study was performed in 175 uncomplicated pregnancies at 13-25 gestational weeks. Doppler flow examinations of the subplacental spiral arteries were done., Results: In the 175 normal pregnancies, both the predicted systolic/diastolic ratios(S/ D) (Y = 1.96258-0.02061x gestational age (GA), adjusted R2 = 0.03773, p = 0.003) and resistance indices (RI) (Y = 0.52131-0.00871 x GA, adjusted R2 = 0.03797, p = 0.003) of the subplacental spiral arteries decreased progressively with advancing gestational age. The predicted S/D value of the subplacental spiral artery decreased from 1.695 at the 13th week's gestation (5th% = 1.221, 95th% = 2.169) to 1.468 at the 24th week's gestation (5th% = 1.057, 95th% = 1.878). The predicted RI value of the subplacental spiral artery also decreased from 0.408 at the 13th week's gestation (5th% = 0.193, 95th% = 0.623) to 0.312 at the 24th week's gestation (5th% = 0.148, 95th% = 0.477)., Conclusions: Normal blood flow resistance of the subplacental spiral arteries at 13-25 gestational weeks decreases progressively with advancing gestational age. The fact suggests that trophoblastic invasion of the spiral arteries occurred continuously throughout normal second-trimester pregnancies.

Two cases of primary malignant peritoneal mesothelioma, a rather rare neoplasm, are reported. It is often mistaken by gynecologists for other, more common neoplasms such as ovarian cancer. The diagnosis is mainly established by laparotomy for tissue proof. There is no uniform agreement on the most appropriate therapeutic modalities to manage this tumor. Surgical resection is too technically difficult to achieve a satisfactory result. The response rate to chemotherapy or radiation is poor. The prognosis for primary malignant peritoneal mesothelioma is poor, with median survival from the time of diagnosis of less than 1 year, despite of aggressive treatment. A review of the literature is also presented.

A 29-year-old female patient visited our out-patient department (OPD) due to primary infertility in March 1993. Hysterosalpingography revealed cervical canal stricture. Gamete intra-Fallopian transfer (GIFT) was performed on Apr. 10, 1993 after ovulation induction. Three oocytes were placed into each Fallopian tube, then the patient was afflicted with lower abdominal discomfort and fullness 2 weeks later. Ovarian hyperstimulation syndrome (OHSS) was diagnosed. Ultrasonography showed intrauterine twin pregnancy and bilateral tubal pregnancy. During admission, supportive care for OHSS and expectant management only for ectopic pregnancies were given. OHSS resolved gradually. After a series of sonographic follow-up, disappearance of fetal heart beat (FHB) in the left ectopic gestational sac, resolution of bilateral ectopic gestational sacs and normal growth of intrauterine pregnancies were noted. On Dec. 16, 1993, the patient received cesarean section (C/S) due to twin pregnancy with vertex and breech presentation at the 37th gestational week. Twin A was female. Birth weight was 2590 gm. Apgar scores at 1 and 5 min. were 7 and 9. Twin B was also female. Birth weight was 2930 gm. Apgar scores at 1 and 5 main. were 8 and 9. Urinary bladder was injured accidentally at C/S. Repairment was done. The patient and her twins were discharged one week later in stable condition. Literature on heterotopic pregnancy after assisted reproductive technique (ART) was reviewed and discussed in this article.

Background: An oral synthetic 19 norsteroid (gestrinone) characterized by antigonadotropic activity and antioestrogenic properties provides its use in the treatment of oestrogen depending pathologic conditions. The purpose of this open study is to evaluate the efficacy and tolerance of gestrinone in the treatment of endometriosis., Methods: Twenty premenopausal women with laparoscopically confirmed endometriosis received 2.5 mg gestrinone two times per week for six months. Laparoscopy was performed before treatment, and clinical responses were determined by second laparoscopy after six months. Serum CA-125 level, plasma lipid and bone density measurements during and after therapy were compared with baseline., Results: The mean endometriosis score, defined by the revised American Fertility Society scoring system, decreased from 20.16 to 4.68 (p < 0.01). The mean serum level of CA-125 also declined from 44.04 U/ml to 18.64 U/ml (p < 0.01). Metabolic studies showed a significant decrease of cholesterol in high-density lipoprotein (p < 0.05), a moderate increase in low-density lipoprotein (p > 0.05), and a slight increase in both triglyceride and total cholesterol levels (p > 0.05). Bone density in this study also showed no significant difference in either spine or femur neck for a duration of six months treatment. Hot flush occurred in less frequency in gestrinonetreated group than in gonadotropin releasing hormone agonist (GnRHa-treated group), where the side effects of weight gain and acne were less often than in the danazol group well., Conclusions: Gestrinone 2.5 mg given twice a week for six months provides an effective and safe treatment for those women suffering from endometriosis.

Background: Epithelial ovarian tumors of borderline malignancy are different from benign tumors and malignant neoplasms. They exist with relatively benign clinical course, younger age and better prognosis as compared with invasive malignant carcinomas. Most of them are discovered at early stage, for example, stage Ia. This retrospective review evaluates the clinical features, treatments and prognosis of 48 patients with borderline malignancy of ovarian tumors., Methods: Forty-eight patients with ovarian tumors of borderline malignancy, aged from 14 to 69 years (mean: 39.2 years; median: 36 years), were retrospectively studied. The histopathologic diagnosis was based on the morphologic criteria published by Tazelaar et al. in 1985. All cases, including 16 cases diagnosed before 1985, were pathologically reviewed. All information of clinical stage, surgical intervention and prognosis was achieved by reviewing hospital record or contacting patients by telephone. Two patients were lost to follow up. One patient died of sepsis resulting from another operation for another gynecological cancer. Totally forty-five patients were included for evaluation., Results: Thirty-nine of the 48 patients (81.3%) were at stage Ia, 6 cases (12.5%) were at stage Ib, 2 cases (4.1%) were at stage Ic, and the remaining one patient (2.1%) was at state IIIc. Thirty-four patients (71%) were with mucinous cystadenoma of borderline malignancy, 11 cases (23%) were of serous type, and 3 patients (6%) were of mixed serous and mucinous type. Twenty-two patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO), but one of them remained partial ovary due to young age (27 y/o). Twelve patients were treated with unilateral oophorectomy or unilateral salpingo-oophorectomy (USO). Twelve patients underwent USO and wedge resection of contralateral ovary. One case underwent debulking surgery. One patient underwent enucleation of ovarian tumor and biopsy of contralateral ovary. Eighteen patients were treated with chemotherapy after operation. One patient developed recurrence 4 months after the primary operation. Excluding two cases lost to follow up and one case with surgical mortality for another gynecological cancer, forty-five patients were alive and were followed from 9 months to 165 months. (median: 48 months; mean: 46 months), Conclusions: Most of the patients were at the early stage of disease when first diagnosed, 81.3% were at stage Ia and only one case was at stage IIIc. Sixty-three percent of our patients underwent surgical treatment alone while the rest of them (37%) had post-operative chemotherapy with either alkeran or PAC. The use of adjuvant chemotherapy seemed unwarranted as there was no difference in survival between those with and without it. (P > 0.05) The low recurrent rate of 2% in our patients again confirmed the 9 P relative benign clinical course of this disease.

Background: Administration of superactive agonistic analog of gonadotropin-releasing hormone (GnRH) has shown to induce a paradoxic and reversible suppression of gonadotropins, so that gonadal steroid concentrations are suppressed and hypoestrogenemia is induced. In order to compare the efficacy and safety of leuprorelin acetate depot (LA) and danazol in the treatment of endometriosis, we conducted this study., Methods: A total of forty-five patients with pelvic endometriosis of different severity at laparoscopy with biopsy of peritoneal implants (n = 33) and surgical procedure (enucleation of ovarian chocolate cysts, cystectomy, or fulguration, n = 12) were included in the study and followed during the 20 weeks of treatment. LA 3.75 mg was injected subcutaneously every 28 days, while the daily oral dose of danazol was 800 mg., Results: Both treatments were associated with a lowering of severity score. There was a consistent decrease in women with stage IV disease in the LA group and an increase in patients with stage I disease in the danazol group, but no difference was found between both treatments. Hot flushing was the most common side effect reported in 97% of LA but occurred only in 13% of danazol-treated patients. In contrast, the androgenic, anabolic side effects of weight gain and myalgia were common in those receiving danazol. The CA-125 levels were significantly lower in both treatment groups compared with their pretreatment levels (p < 0.01). During the five months of the LA treatment, biochemical evaluation revealed no pathologic alternation. Only total protein albumin, alkaline phosphatase, total bilirubin, total cholesterol, high density lipoprotein-cholesterol, low density lipoprotein-cholesterol, uric acid and calcium increased significantly. Danazol was also associated with adverse metabolic effects and significantly increased low-density lipoprotein-cholesterol concentrations (p < 0.05). In the fourth week, serum estradiol (E2) levels decreased to nearly castrated levels (13.87 +/- 1.63 pg/ml) in all patients treated with LA, and remained at this level thereafter. On the contrary, a slight but significant increase of the serum E2 levels was noted during the danazol treatment. After five months of treatment with LA, no significant changes in bone density were observed at the femoral neck or the anteroposterior (AP) view of lumbar spine, but there was a significant loss in bone density at the lateral view of lumbar spine (-7.1%, p < 0.05)., Conclusions: Both LA and danazol are effective in the treatment of endometriosis. The hypoestrogenic side effects of LA may be better tolerated than the androgenic, anabolic effects of danazol. However, the danazol treatment costs less than LA and has no significant side effect with osteoporosis.

Background: A pregnancy in patients treated with gonadotropin-releasing hormone agonists (GnRHa) using follicle-stimulating hormone (FSH) alone was first reported by Shaw et al. in 1991. Recently, several comparative trials have shown that FSH is as effective as human menopausal gonadotropin (hMG) in this indication. In other words, the residual endogenous levels of luteinizing hormone (LH) in GnRHa treated cycles may be generally sufficient to support FSH-induced follicular development to exempt from the co-administration of exogenous LH., Methods: A total of 42 consecutive candidates for in vitro fertilization (IVF) participated in a prospective randomized study. In this study, the efficacy of two different gonadotropins (Pergonal and Metrodin, Serono, Italy) in inducing ovulation was investigated. All treated women were less than 40 years of age and had received a long desensitized protocol by a GnRHa (Leuprolide acetate, Takeda or Decapeptyl, Ferring). Ovarian inactivity was monitored by plasma estradiol and LH concentration. After the pituitary gland was down-regulated, all patients were given either hMG (n = 25) or FSH (n = 17) for controlled ovarian hyperstimulation (COH)., Results: The mean number of gonadotropin ampoules and the peak estradiol level were significantly higher in hMG group than in the FSH group. No significant differences were found between both groups in the incidence of cancelled cycles, failed oocyte recovery, mean number of oocytes recovered per patient, the fertilization and embryo cleavage-rate. However, the hMG group demonstrated a higher pregnancy and abortion rate., Conclusions: There is no significant difference between hMG and FSH stimulation when used following GnRHa desensitization for COH, so the cost should be considered.

Background: As an estrogen derivative, estriol is rather effective in the relief of climacteric symptoms due to estrogen deficiency. When given one dose a day, it will not provoke endometrial proliferation and shedding. Thus, it is suitable for postmenopausal women who no longer want to have uterine bleeding and for those with comparatively higher risk of endometrial hyperplasia. In the aspect of postmenopausal osteoporosis, the prevention of further bone loss due to estrogen deficiency is also important and to be evaluated., Methods: We collected 20 patients, aged 44-62 years, who had undergone either natural or surgical menopause and were treated with estriol succinate (Synapause; Organon; Holland 2 mg/tab) 2 mg/day for 2 years, with relief of climacteric symptoms evaluated after the first 3 months of treatment. Bone mineral density (BMD) of lumbar spine was measured using quantitative computed tomography (QCT) after one and two years of treatment, respectively., Results: Estriol was very effective in the improvement of major subjective climacteric complaints in 86% of patients, especially hot flush and insomnia within 3 months. The atrophic genital changes caused by estrogen deficiency were also improved satisfactorily. No subjective symptoms induced by the therapy were seen. The rate of uterine bleeding was low, complained by only one patient. However, our study did not show the preventive effect of estriol against osteoporosis., Conclusions: Estriol can be a safe and effective alternative in the relief of climacteric symptoms for postmenopausal women, but it cannot prevent the bone loss.

Electroejaculation to produce semen from anejaculated males has been employed successfully in conjunction with intrauterine insemination (IUI), in vitro fertilization/embryo transfer, and gamete intrafallopian transfer. We herein report the use of IUI to achieve pregnancy following electroejaculation in a patient with primary idiopathic anejaculation. This 30-year-old patient had a history of anejaculation that was noted after marriage, but had normal sexual potency and occasional nocturnal emission. Electroejaculation was successfully used to obtain semen. The highly motile sperm was recovered from swim up procedure and used for IUI. The 25-year-old wife was given clomiphene citrate and Pergonal for ovulation induction. A triplet pregnancy was achieved. At 26 weeks of gestation, the first triplet was delivered after spontaneous rupture of membrane. We tried to delay delivery of this retained twin pregnancy. Thirty-two days later, the remaining two fetuses were delivered weighing 1100 gm and 900 gm. Ninety-three days after delivery, these two babies were discharged, putting on weight to 3564 gm and 3264 gm. This case represents the first success of using electroejaculation to achieve pregnancy from anejaculated patient in Taiwan.

Background: Assisted conception not only raises the pregnancy rate by treating infertility, but also increases the chance of obstetrical complication of multiple pregnancy. So it is important to develop a means by which the number of developing embryos can be reduced., Methods: Eight multiply pregnant women (from triplets to octuplets) asked to have the number of viable fetuses reduced. By means of sonar guided puncture, a mixture of demerol and xylocaine was injected to the fetal thorax until the fetal heart ceased to beat. The procedures were done between the 7th and 11th week of gestational age. Repeated scans were done for three consecutive days to confirm the viability of the remaining fetuses., Results: Except for vanishing twins, no serious complication was noted. For six of the women, 10 healthy births have resulted; the remaining two have ongoing pregnancies., Conclusions: The procedure described is an easy, safe and effective method to diminish obstetrical morbidity of multiple pregnancy.

The significance of transiently increased serum prolactin (PRL) levels on pregnancy rates in vitro fertilization (IVF) is unknown. The aim of this study was to evaluate PRL levels in IVF patients who conceived and in matched controls who did not. Ten IVF cycles resulting in pregnancy and forty nonpregnant cycles were compared. Prolactin was measured before ovarian stimulation with gonadotropins and estradiol (E2), progesterone (P) and PRL were measured 36 hours, 12 hours, 10 minutes before and 12 hours after human chorionic gonadotropin (hCG) administration at mid-cycle. Serum PRL levels at various time were not significantly higher in the nonpregnant women than in the pregnant women. Twelve hours before hCG, P levels were significantly higher in the nonpregnant women than in the pregnant women (1.5 +/- 0.2 ng/ml [mean +/- standard error] and 0.9 +/- 0.3 ng/ml, respectively; P < 0.05). All women had transient hyperprolactinemia for one to three times during ovarian hyperstimulation. There was no correlation between PRL and E2 in either group. These results do not support the treatment of transient hyperprolactinemia with dopamine agonists in IVF patients.

Cervical cancer is a predomiannt gynecologic neoplasia in Taiwan. The associations of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and squamous cell carcinoma antigen (SCC-Ag) for detection of cervical cancers with type of cancer, clinical stage and lymph node metastasis were studied. Serum samples were collected from 395 patients with cervical cancers (61 CIN3, 334 squamous cell carcinoma, 18 adenocarcinoma), 72 patients with benign gynecologic diseases and 115 healthy controls. The sensitivities of CEA, TPA, and SCC-Ag were 15.2%, 33.6%, and 49.3%. The specificities were 89.3%, 96.2%, and 95.1%, respectively. The positive rate of CEA was found significantly higher among patients with adenocarcinoma than those with squamous cell carcinoma. The positive rate of CEA and SCC-Ag increased with advance of the clinical stages. There was no significant difference in the rate of each tumor marker between patients with lymph node metastasis and those without metastasis. The positive rate obtained by SCC-Ag alone was comparable to those by the combinations of two or three antigens. The result of the present study indicates that SCC-Ag is the most useful tumor marker in the detection of cervical cancers.

From January 1986 to June 1990 at Veterans General Hospital-Taipei, 12 cases of placenta accreta were reviewed. The incidence were 1 per 1,101 deliveries. Eight cases were confirmed by pathological examination, and the incidence was 0.06% (1/1,652). Placenta previa was found in 7 cases (58.3%); 6 of them had history of cesarean section. All the cases had history of uterine surgery. Seven cases underwent cesarean section, and the other one received myomectomy. Hysterectomy was performed on 6 patients, and conservative treatments were employed on the other 6 cases. No maternal mortality occurred. Besides one case of missed abortion, there was only one perinatal loss due to immaturity. Accurate prenatal diagnosis of placenta accreta by ultrasound was obtained in 4 cases. Although hysterectomy is the definite treatment of placenta accreta, conservative managements should be tried before this intervention.

Chemosensitivity test has its role in cancer therapy. Using an accurate, efficient, and simple way to choose the proper chemosensitive drugs in our clinical study will help advance our work. The MTT assay is a rapid, precise, and new method to perform drug sensitivity assay. We used an ovarian cancer cell line (OC-3L-VGH) to compare the accuracy of the MTT and the [3H]-TdR incorporation assay in measuring chemosensitivity of 7 anticancer drugs. Good correlation was observed between the MTT and the [3H]-TdR assay for drug sensitivity testing (r = 0.893, P less than 0.001). Based on this study we found it may be preferable to use the MTT assay for chemosensitivity screening.

Twenty five patients with endometriosis of varying degree had been treated with Buserelin (GnRH analogue) for 6 months. Among them, 83.4% reached castrated level by measuring the serum estradiol (E2) 2 months after therapy. Dysmenorrhea was alleviated or completely disappeared during therapy. Hot flush was the one mostly complained. Vaginal dryness was the second and decreased libido the third. Persisted periodic bleeding was noted in 3 patients. Ovulation was suppressed as evidenced by low serum progesterone throughout the whole course of treatment. Second-look laparoscopy was done at the end of 6-month therapy. Scoring assigned by the American Fertility Society (AFS) was reduced by 27.5%. The adrenal gland, liver and renal functions as well serum calcium and phosphate were retained at the end of treatment. Ovulation and menstruation also returned to normal within 2 months after cessation of therapy. There were 4 pregnancies during the 6-month follow period (4/15 = 26.6% pregnancy rate). 7 patients had improved symptoms whereas 7 patients sustained recurrent dysmenorrhea. The hormonal profile showed that dysmenorrhea improved group had better ovarian suppression than the dysmenorrhea recurrent group.

In the past 20 years, approximately half of the 25 women with granulosa cell tumor of the ovary studied, were dead. The results showed that recurrence or metastasis had a statistically significant correlation with survival. The other factors, such as the patients' age, the content of the tumor, ascites, endometrial change, mitosis and rupture, have no relationship with the survival rate in our study.

This retrospective study collected the surgical tissues and the clinical records of 197 surgically treated patients with microinvasive carcinoma of the cervix, which was defined as a limited microinvasion not more than 3 mm in depth regardless of lymph-vascular involvement. Depth of invasion was 1 mm or less in 13.2% and 1.1 to 3 mm in 86.8%. The mean age was 47.2 years. About half of the patients were asymptomatic but suspected cytologically. Random cervical biopsy alone was inadequate for diagnosis. Cone biopsy demonstrated an accuracy of 94% in diagnosis, but failed to eliminate microinvasive carcinoma in 23.0% of the hysterectomy specimens. In 14 cases, the invasion was more extensive in the uterus than in the cone. A positive correlation has been found between the diagnostic rate of conization and the depth of stromal invasion. Cervical conization, while relatively accurate in assessing the existence of stromal invasion that characterizes microinvasion, failed to diagnose those with deeper stromal invasion, especially beyond 1 mm. The recommended approach in diagnosing microinvasion is careful colposcope-directed cone biopsy and proper examination of the conization specimen in order to exclude the possibility of more advanced disease.

A review of 42 patients with vaginal intraepithelial neoplasia (VAIN) seen in Gynecologic Department of Veterans General Hospital-Taipei between 1971 and 1987 was made. The patients were from 36 to 79 years of age with a mean 58 of years. Fifteen patients (36%) had synchronous cervical neoplasia, 26 cases (62%) had antecedent cervical neoplasia and one had undergone operation for uterine myoma. Twenty-four of 27 patients with VAIN alone presented an abnormal Papanicolou smear. The upper one third of the vagina was the most common site of the lesion. Multifocal lesions were demonstrated in 58% cases while unifocal disease accounted for 42% cases who had VAIN subsequent to cervical neoplasia. Colposcopically directed biopsies were used for diagnosis in 13 patients. White epithelium and punctation were the most common findings of VAIN. While the results of different treatments were reviewed, surgical excision was found to be the most frequently employed method and radiotherapy was the second. Both were effective and 5 patients died of vaginal disease. On account of the relatively benign nature of VAIN than that of invasive vaginal cancer and the need for preservation of a functional vagina, more conservative approaches, for example, topical 5-Fluorouracil application and carbon dioxide laser vaporization, are discussed.

From January 1976 through December 1985, 895 patients with cervical carcinoma were treated with radical hysterectomy and pelvic lymphadenectomy. The surgical specimens of 23 cases were proved to be adenosquamous cell carcinoma, the incidence being 2.6%. Among them, 15 were at stage IB, 7 were at stage IIA and one was at stage IIB. The overall 5-year survival rate was 55.0% and there was no difference between patients at stage IB and IIA. During the same period the 5-year survival rate of squamous cell carcinoma was 87.5% for patients at stage IB and 75.0% for patients at stage IIA. Pelvic lymph node metastasis and parametrial involvement are considered to be poor prognostic factors. When metastasis or invasion happens, the metastatic or invasive lesions can be found in the form of pure squamous carcinoma or adenocarcinoma. Postoperative adjuvant radiotherapy (external irradiation plus brachytherapy) seems to be effective in preventing recurrence. Chemotherapy (PVB regimen) needs more clinical evaluation. In this study, when metastasis or recurrence developed, the response to radiotherapy and/or chemotherapy were poor and 75% of patients died within one year.

To have a better understanding of rubella seroepidemiology among female population in Taiwan, we report a serologic survey of 4030 examinations for 2030 school girls and 2000 pregnant women, using enzyme-linked immunosorbent assay for the detection of rubella specific IgG. RA 27/3 vaccines were given to susceptible volunteer students and postpartum women for the evaluation of vaccine efficiency and its side effects. The results showed that the rubella susceptible female among 8 to 22-year-old girl students was 44.97%, which was higher than expected, as most of them experienced the outbreak of rubella in 1977. The susceptibility rate among the pregnant women was 19.35%, which was also higher than expected for an age group having been through two outbreaks in the past. All the vaccinees showed good tolerance to the vaccine and the seroconversion rate was 100%. With such high susceptibility rate among women of child bearing age and girl students, plus the endemic property of rubella infection in Taiwan, we can expect a high risk of congenital rubella syndrome. Mass vaccination against rubella should be brought into effect immediately.