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Context: Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication of assisted reproduction. OHSS is induced by an ovarian release of vasoactive, angiogenic substances that results in vascular hyperpermeability, leakage, and shift of fluids from blood vessels into the extravascular space with consequent ascites and edema that are attributed to vascular endothelial growth factor (VEGF)., Objective: Our objective was to examine a physiological approach for preventing and treating OHSS, based on negating the VEGF network., Design: We used a mouse OHSS model and cultured granulosa cells., Main Outcome: Changes in pigment epithelium-derived factor (PEDF) and VEGF were measured by quantitative PCR and Western blot analysis. OHSS was recorded by changes in body weight and in peritoneal vascular leakage, quantified by the modified Miles vascular permeability assay., Results: Granulosa cells produced and secreted the anti-angiogenic factor, PEDF, in an inverse fashion to VEGF. The physiological PEDF-VEGF counterbalance was found to be impaired in the mouse OHSS model. Treatment of OHSS-induced mice with low doses of recombinant PEDF (rPEDF) alleviated OHSS signs including edema (P < .001) and vascular leakage (P < .001) and reduced the level of ovarian VEGF mRNA. Low doses of rPEDF also reduced VEGF mRNA levels in granulosa cells in vitro. However, these effects were not seen at higher doses of rPEDF, suggesting a hormetic mechanism of rPEDF action., Conclusion: These observations provide a new perspective into the pathophysiology of OHSS, namely, high expression level of VEGF together with a nearly undetectable level of PEDF. A replacement therapy with rPEDF is suggested as an innovative physiological treatment for OHSS. Finally, control of the PEDF-VEGF reciprocal relationship could open new therapeutic avenues for other angiogenic-related fertility pathologies.

Angiogenesis is critical for the development of ovarian follicles. Blood vessels are abrogated from the follicle until ovulation, when they invade it to support the developing corpus luteum. Granulosa cells are known to secrete anti-angiogenic factors that shield against premature vascularization; however, their molecular identity is yet to be defined. In this study we address the physiological role of pigment epithelium-derived factor (PEDF), a well-known angiogenic inhibitor, in granulosa cells. We have shown that human and mouse primary granulosa cells express and secrete PEDF, and characterized its hormonal regulation. Stimulation of granulosa cells with increasing doses of estrogen caused a gradual decrease in the PEDF secretion, while stimulation with progesterone caused an abrupt decrease in its secretion. Moreover, We have shown, by time- and dose-response experiments, that the secreted PEDF and vascular endothelial growth factor (VEGF) were inversely regulated by hCG; namely, PEDF level was nearly undetectable under high doses of hCG, while VEGF level was significantly elevated. The anti-angiogenic nature of the PEDF secreted from granulosa cells was examined by migration, proliferation and tube formation assays in cultures of human umbilical vein endothelial cells. Depleting PEDF from primary granulosa cells conditioned media accelerated endothelial cells proliferation, migration and tube formation. Collectively, the dynamic expression of PEDF that inversely portrays VEGF expression may imply its putative role as a physiological negative regulator of follicular angiogenesis.

Objective: To address the consequences of surgical curettage following failed medical abortion., Methods: A retrospective case-control study was performed in a tertiary gynecologic department. The case group comprised 104 women who underwent surgical curettage following failed medical abortion; the control group included 104 women who underwent early surgically induced abortion. Clinical characteristics and surgical findings were examined. The extent of inflammation was quantified following immunohistochemical staining for cell-surface markers characteristic of T lymphocytes, B lymphocytes, and macrophages. The extent of necrosis was evaluated morphologically., Results: Abnormal findings during surgical curettage were significantly more prevalent among women in the case group than in the control group (10.6% versus 1.9%; P=0.019). The most frequent abnormality in the case group was the presence of intimately adherent products of conception, necessitating sharp curettage. The extent of inflammation (represented by increased numbers of T and B lymphocytes) was greater in the case group than in the control group (P=0.046 and P=0.001, respectively), as was the extent of necrosis (P<0.05)., Conclusion: Curettage following failed medical abortion harbors particular difficulties, which may be attributed to an inflammatory response. The long-term consequences of curettage following failed medical abortion warrant further investigation., (Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To characterize the clinical and laboratory features of coagulopathy following second-trimester surgical abortions. DESIGN. Retrospective study., Setting: Gynecologic unit of a university-affiliated medical center., Population: 1249 consecutive women underwent late second-trimester (16-24 weeks) surgical abortions between January 2002 and June 2010. Of those, 20 women (1.6%) were diagnosed with excessive bleeding accompanied by coagulopathy., Methods: Women were divided into two groups based on whether the abortion was performed for fetal demise (n=14) or pregnancy termination (n=6)., Main Outcome Measures: Gestational age, indication for abortion, blood clotting tests, number of blood products and coagulation factors administered., Results: Women who had pregnancy termination began to bleed significantly earlier than those with fetal demise (p<0.05). A significantly higher number of women with fetal demise had a gradual deterioration of the clotting test, compared with women who had pregnancy termination (p<0.05). In women with fetal demise, early bleeding was associated with a more severe clinical presentation., Conclusions: Coagulopathy following surgical abortion manifests differentially in women who have fetal demise and those who have pregnancy termination, implying a different pathophysiology. Women with fetal demise suffering from excessive bleeding following surgical abortion accompanied with mild clotting test abnormalities should be carefully monitored to diagnose and treat an impending disseminated intravascular coagulation., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica © 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)

G(q) protein-coupled receptors (G(q)PCRs) regulate various cellular processes, including mainly proliferation and differentiation. In a previous study we found that in prostate cancer cells, the G(q)PCR of gonadotropin-releasing hormone (GnRH) induces apoptosis by reducing the PKC-dependent AKT activity and elevating JNK phosphorylation. Because it was thought that G(q)PCRs mainly induce activation of AKT, we first undertook to examine how general this phenomenon is. In a screen of 21 cell lines we found that PKC activation results in the reduction of AKT activity, which correlates nicely with JNK activation and in some cases with apoptosis. To understand further the signaling pathways involved in this stimulation, we studied in detail SVOG-4O and αT3-1 cells. We found that prostaglandin F2α and GnRH agonist (GnRH-a) indeed induce significant Gα(q)- and PKC-dependent apoptosis in these cells. This is mediated by two signaling branches downstream of PKC, which converge at the level of MLK3 upstream of JNK. One branch consists of c-Src activation of the JNK cascade, and the second involves reduction of AKT activity that alleviates its inhibitory effect on MLK3 to allow the flow of the c-Src signal to JNK. At the MAPKK level, we found that the signal is transmitted by MKK7 and not MKK4. Our results present a general mechanism that mediates a G(q)PCR-induced, death receptor-independent, apoptosis in physiological, as well as cancer-related systems.

Objective: To report the responses to IVF surrogacy attempts in a female with a heretofore never described combination of Mayer-Rokitansky-Kuster-Hauser (MRHK) syndrome and triple X karyotype., Design: Case report., Setting: Reproductive unit of a university-affiliated medical center., Patient(s): A 29-year-old female diagnosed as having both MRHK syndrome and a triple X (47XXX) karyotype., Intervention(s): Five cycles of IVF surrogacy., Main Outcome Measure(s): Recovery of oocytes after controlled ovarian stimulation., Result(s): A maximum of five oocytes were retrieved by percutaneous abdominal aspiration of a single subcostal left ovary. After five unsuccessful IVF trials due to low ovarian response attributed to her coexisting MRHK syndrome and triple X karyotype, the patient's choice was oocyte donation., Conclusion(s): An abnormal karyotype can coexist with MRKH syndrome, albeit very rarely, and probably accounts for a low ovarian response to attempts to achieve IVF surrogacy., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to investigate the reproductive outcomes of women who underwent laparoscopic removal of benign cystic teratoma with or without intraoperative spillage., Study Design: The reproductive outcomes of reproductive age women following laparoscopic removal of benign cystic teratoma from 1997 through 2007 were investigated by a telephone questionnaire., Results: In all, 128 reproductive age women underwent benign cystic teratoma removal, and reproductive outcomes were available for 45. Among those 45 women, intraoperative spillage occurred in 16 (35.6%). The rate of spontaneous pregnancies was significantly lower for the nonspillage compared to the intraoperative spillage groups (20/29 [68.9%] vs 16/16 [100%], respectively; P = .01). However, the median time from surgery to the first pregnancy was similar (22 and 18.5 months, respectively; P = .9). From the 9 remaining women in the nonspillage group, 4 conceived with ovulation induction, 2 conceived with in vitro fertilization, and 3 were infertile., Conclusion: Intraoperative spillage of benign cystic teratomas does not lead to long-term infertility., (Copyright © 2010 Mosby, Inc. All rights reserved.)

Study Objective: To assess the efficacy of oophoropexy in obviating recurrent torsion and its possible long-term effects., Design: Case series and review of the literature (Canadian Task Force classification III)., Setting: University hospital., Patients: Women who underwent oophoropexy for recurrent torsion of normal adnexa between 2003 and 2008., Measurements and Main Results: Retrieved information included the indication for oophoropexy, surgical methods, recurrence, and follow-up. Seven women underwent oophoropexy during the study period because of recurrent torsion of normal adnexa. One additional patient had experienced 3 torsion events of cystic adnexa. Surgical methods included suturing of the ovary to the pelvic sidewall or to the round ligament and plication of the utero-ovarian ligaments. Recurrence occurred in 1 of 6 patients for whom follow-up was available. All 6 patients reported spontaneous menstruation, and 2 conceived spontaneously and gave birth. Ultrasound at long-term follow-up (9-58 months) demonstrated normal ovaries., Conclusion: Oophoropexy seems to be efficacious in preventing recurrent torsion. It is our impression that plication of the utero-ovarian ligaments has advantages over other approaches insofar as surgical feasibility and anatomical conservation., (Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To report a higher than estimated recurrence rate of benign mucinous cystadenomas after complete resection of the first one, and to assess potential risk factors for recurrence after complete surgical excision., Study Design: We retrospectively reviewed all cases of women who underwent either laparoscopic or laparotomic removal of benign mucinous adnexal cysts by either adnexectomy or cystectomy in our institution between 1996 and 2006., Results: Included were the data of 42 women who fulfilled study entry criteria. Three of them (7.1%) underwent a second operation because of a recurrence of the lesion. A significantly higher rate of women who had cyst recurrence had undergone cystectomy as opposed to adnexectomy (P < .05). Intraoperative rupture of cysts during cystectomy was also significantly associated with cyst recurrence (P < .03)., Conclusion: Mucinous cystadenoma recurrence is apparently not as rare as reported in the literature. Intraoperative cyst rupture and cystectomy instead of adnexectomy emerged as being two risk factors for recurrence., (Copyright 2010 Mosby, Inc. All rights reserved.)

Study Objectives: To investigate the phenomenon of recurrent adnexal torsion during the same pregnancy, describe its risk factors, and suggest possible management of this entity., Design: Retrospective case-control study (Canadian Task Force classification II-3)., Setting: Gynecologic endoscopy unit in a university hospital., Patients and Interventions: Pregnant women with surgically proved adnexal torsion were retrospectively identified from 1993 to 2007. Details of clinical presentation, method of conception, preoperative ultrasound findings, and operative findings were analyzed., Intervention: Comparison of characteristics of patients with recurrent episodes of adnexal torsion during the same pregnancy vs a single episode of torsion., Measurements and Main Results: Thirty-three pregnant women with 38 episodes of adnexal torsion were included in the study. Seventeen pregnancies (51.5%) were spontaneously conceived. Twenty-eight women had a single episode of torsion, and 5 women (15.1%) had recurrent episodes of torsion during the same pregnancy. No significant differences were found between the 2 groups in age, method of conception, and gestational age at time of torsion. However, ultrasound studies demonstrated that multicystic ovaries were significantly more common in women with recurrent torsion compared with women with a single episode of torsion (80% vs 25%; p =.02). The interval between the first and second episodes of torsion ranged from 1 to 4 weeks., Conclusion: Pregnant women are at risk for recurrent torsion, especially when the ovaries are enlarged and ultrasound studies demonstrate multiple cysts. Cyst aspiration may prevent recurrent torsion during the same pregnancy.

Objective: To assess whether there is an increased perioperative risk in termination of late second-trimester pregnancy after multiple cesarean sections by laminaria dilatation and evacuation., Study Design: During the period between January 2002 and June 2008, 636 consecutive patients underwent late second-trimester (17-24 weeks) pregnancy terminations by dilatation and evacuation. Patients were divided into 3 subgroups: those with no previous cesarean section (n = 545), those with 1 previous cesarean section (n = 59), and those with several previous cesarean sections (n = 32)., Results: There were no significant differences in major perioperative complications, such as anesthetic complications, need for blood transfusion, and cervical lacerations comparing the 3 subgroups. Importantly, there were neither cases of uterine perforation nor retained products of conception in the 3 subgroups., Conclusion: Late second-trimester pregnancy termination after multiple cesarean sections by laminaria dilatation and evacuation is probably not associated with an increased perioperative risk. Larger studies are needed to empower this study.

Objective: The study compares the perioperative morbidity and mortality rates of elderly (>or=70 years) and younger (<70 years) patients with endometrioid endometrial cancer., Methods: The study cohort consisted of 115 consecutive women undergoing explorative laparotomy because of endometrioid endometrial cancer. Clinical data included patients' age, comorbidities, chronic use of medications, body mass index (kg/m), previous surgical procedures, surgical International Federation of Gynecology and Obstetrics stage, histological grade, relevant prognostic factors, a number of dissected lymph nodes, occurrence of perioperative complications, postoperative hospital stay (in days), and long-term disease-specific survival (in months)., Results: Patients were divided into 2 groups: those younger than 70 years (group 1: 84 women, 73%) and those 70 years or older (group 2: 31 women, 27%). Although, as expected, elderly women had more major comorbidities, the rate of perioperative complications was similar between the 2 groups. In a logistic regression model, only chronic lung disease, gastrointestinal disease, and past abdominal surgery correlated with a higher rate of perioperative complications. None of the cohort patients died during the perioperative period. The long-term disease-specific survival was significantly poorer for the older group., Conclusion: Chronological age by itself should not be a contraindication for the proper surgical treatment of elderly women with endometrioid endometrial cancer, because it is a poor predicting factor for perioperative morbidity and mortality.

Objective: To define the predictors discriminating between patients developing tuboovarian abscess (TOA) and those with non-TOA acute pelvic inflammatory disease (PID) on the day of admission to the hospital., Study Design: One hundred sixty-three patients were evaluated and divided into 2 groups: 42 patients diagnosed with clinical and sonographic evidence of TOA and 121 diagnosed with PID. Relying upon the significant differences between the 2 groups, cutoff levels yielding the best degree of discrimination were determined., Results: A palpable adnexal mass in a woman older than 42 years and erythrocyte sedimentation rate > 50 mm/h were the best predictors of TOA. There was no difference in the mean temperature or number of sick days prior to hospitalization., Conclusion: Our results suggest that there are parameters that can be used as predictors of TOA and prolonged hospital stay. These parameters can advance the beginning of more aggressive antibiotic treatment.

Objective: To assess the indications for prenatal karyotyping of sex chromosomal abnormalities (SCAs) during pregnancy., Methods: All singleton pregnancies interrupted in our institute because of SCAs (1998-2005) were categorized into subgroups of 45,XO (Turner syndrome), 47,XXY (Klinefelter syndrome), 47,XXX and 47,XYY. The indications for prenatal diagnostic testing were recorded., Results: There were 67 SCAs pregnancies: 33% Turner syndrome, 28% Klinefelter syndrome, 21% 47,XXX and 18% 47,XYY. Maternal age was similar among the 4 groups (34 +/- 5, range 25-42 years). The main indications for fetal karyotyping were abnormal Down's syndrome (DS) screening or ultrasound findings, advanced maternal age (> or =35 years), and parental request. About 2/3 of the Turner and 47,XYY cases had either abnormal DS screening tests or sonographic findings, such as: increased nuchal translucency, mainly cystic hygroma and fetal hydrops. However, fetal karyotyping in more than 2/3 of the 47,XXX and 47,XXY cases was mainly performed because of advanced maternal age, and the diagnosis of fetal SCAs was coincidental (p <0.03)., Conclusions: Our recent suggestion to expand the DS screening capacity to other chromosomal abnormalities including SCAs is further supported. Prenatal detection seems to be promising for Turner syndrome and possibly for 47,XYY syndrome, while other SCAs are less likely to be detected either by ultrasound or biochemical screening., ((c) 2007 S. Karger AG, Basel)

Objective: To assess the distribution of fetal indications leading to termination of pregnancy (TOP) in our institute., Methods: All pregnant women with singleton pregnancies who underwent TOP due to fetal abnormalities in our institute between January, 1998 and December, 2004 were divided between early TOP (<23 weeks' gestation) and late TOP (> or =23 weeks' gestation)., Results: There were 328 (71%) and 134 (29%) early and late TOPs, respectively. The TOPs were performed at a mean gestational age of 20.1 +/- 4.8 weeks. The groups varied significantly in the indications for TOP (p = 0.04), which were primarily structural abnormalities (mostly CNS) followed by chromosomal/genetic defects. Fetal structural abnormalities were more common in the late TOP group (62.7% vs 54.2%) while chromosomal-genetic defects were more common in the early TOP group (40% vs 29.1%, respectively). Fetal infection (mostly cytomegalovirus) was similar ( approximately 4%) for both groups. The early TOP group had significantly more hydrops, gastrointestinal, face and neck abnormalities, while the late TOP group had significantly more cardiovascular abnormalities (p < 0.01)., Conclusions: The impact of early chromosomal/genetic screening contributes to early TOPs, while midgestation anomaly and cardiac scanning significantly contribute to late TOPs. Fetal infection contributes equally to both categories of TOPs.

Background: The Israeli Ministry of Health reported an increased rate of twin pregnancies among all cases locally diagnosed as having open neural tube defects. The current study aimed to evaluate whether the etiology of this phenomenon could be attributed either to the twinning or to the mode of conception., Methods: Women admitted to our hospital between January 1997 and July 2004 for termination of pregnancy because of severe fetal abnormality enrolled into this retrospective case series study. They were further subdivided according to mode of conception (spontaneous, in vitro fertilization (IVF) or intracytoplasmic sperm injection (IVF-ICSI) pregnancies)., Results: Three-hundred and eighty consecutive pregnancies, of which 340 (89%) were singletons, participated in our study. Anencephaly was diagnosed in 26 cases: 19 singletons and 7 twins. In the entire twin population, they were all dichorionic twins and only one co-twin was affected. Five of the twins were conceived by IVF-ICSI. All the anencephalic IVF-ICSI twins had normal karyotypes. All IVF-ICSI study women had taken folic acid 400 mcg/day 3 months before conception and throughout the first trimester of pregnancy. In order to find out the cause of the high rate of anencephaly found in IVF-ICSI pregnancies (33.3%), either the twinning or the IVF-ICSI process, a logistic regression analysis was used. A significant correlation was found only between anencephaly and twinning (p = 0.001, CI = 1.86-12.63), with a risk ratio of 4.85., Conclusions: Our case series data suggest a comparatively higher rate of anencephaly in IVF-ICSI pregnancy secondary to twinning and not because of the assisted reproductive technology. It is suggested that larger epidemiologic studies are conducted to validate our preliminary results., (Copyright 2005 John Wiley & Sons, Ltd.)

We have demonstrated previously that the synthesis of epiregulin and amphiregulin, of the EGF-like growth factor family, is stimulated by luteinizing hormone in human follicular (granulosa) cells obtained from in vitro fertilization program. In the present work, we demonstrate that H89, a PKA inhibitor, attenuated the expression of these growth factors both in the mRNA and the protein levels, suggesting PKA involvement in this signaling pathway. SV40-transformed human granulosa cells showed higher basal levels of epiregulin and amphiregulin than normal cells, which were still elevated following cAMP stimulation by Forskolin. Cleavage by a disintegrin and metalloproteinases (ADAMs) is essential for activation of these growth factors, allowing their interaction with EGF receptor. Expression of ADAMTS1 and ADAM12 was downregulated by cAMP in normal, but not in SV40-transformed cells, suggesting that in normal cells epiregulin and amphiregulin activity is downregulated by a feedback mechanism that may be lost in SV40-transformed cells and their loss of downregulation may be involved in the development of ovarian tumors.

Background: The study aims to compare the diagnostic accuracy of sonographic evaluation versus clinical estimation in women suspected to have retained trophoblastic fragments., Methods: The study group consisted of 68 consecutive patients admitted to our department due to suspected residual trophoblastic tissue. Each woman underwent ultrasound and physical examination by expert clinicians. The clinicians performing the physical examination were not informed of the sonographic findings, and vice versa., Results: Patients were divided into three subgroups: clinical suspicion only of residual trophoblastic tissue (n = 8), sonographic suspicion only (n = 44) and combined sonographic and clinical suspicion of residual trophoblastic tissue (n = 16). In the latter group, in 14 out of 16 women (87.5%) retained trophoblastic tissue was confirmed by histological examination, a significantly higher rate compared to ultrasonographic (45.5%, P < 0.002) or clinical suspicion only (62.5%, P = 0.07). The specificity and positive predictive value of the clinical examination were significantly higher compared to ultrasonographic evaluation (P < 0.05), while the sensitivity of the ultrasonographic evaluation was higher than the clinical estimation (P < 0.05). There was no statistically significant difference in the negative predictive value or in diagnostic accuracy between the two methods., Conclusions: Based on our current experience, it seems that the combination of both clinical and ultrasonographic evaluation is recommended before uterine curettage is performed, thus lowering the rate of unnecessary invasive procedures.

Gonadotropic hormone, luteinizing hormone, and follicle-stimulating hormone exert their effect via activation of G-coupled receptors, which activate the hormone sensitive adenylyl cyclase, protein kinase A, and cyclic AMP responsive elements. This activation leads to specific de novo synthesis of steroidogenic factors and steroidogenic enzymes. In normal cells and following activation of this signaling pathway, desensitization period will be followed. This down-regulation, which was studied in detail for the last three decays, was found to take place at various steps of these signal transduction pathways as well as at different kinetics. A common and diverse feature of the mechanism of desensitization in other G-coupled-7-transmembrane receptor system is also discussed.

Objective: In order to better understand the etiology of the vulvar vestibulitis syndrome, we examined the histopathologic parameters in vestibular mucosa, and compared the findings in specimens obtained from women with vulvar vestibulitis with those obtained from the control group., Study Design: Specimens of vestibulitis were obtained from 24 patients, undergoing circumferential vestibulectomy under general anesthesia due to the symptoms and signs consistent with vulvar vestibulitis. Control specimens were obtained from 16 women, without symptoms or signs of vulvar vestibulitis, undergoing reconstructive introital surgery due to roomy vagina, rectocele or painful episiotomy. All vestibular tissue specimens were examined for intensity of inflammation, extension of inflammatory cells into the epithelium, vascular proliferation, the presence of mast cells and proliferation of peripheral nerve bundles., Results: No significant difference was found regarding the degree of inflammation, the extension of inflammatory cells into the epithelium, the vascular proliferation and the presence of mast cells while comparing the study and the control groups. The only histopathologic feature, differentiating the patients with vulvar vestibulitis from the control group, was the proliferation of peripheral nerve bundles found in 19 out of 24 (79.1%) specimens expressing vestibulitis and in none of 16 control specimens (p < 0.0001)., Conclusion: Our results, therefore, support the existence of peripheral nerve hyperplasia in vestibular tissue obtained from patients with vulvar vestibulitis, and exclude the role of active inflammation or mast cells as probable etiologies for the vulvar vestibulitis syndrome., (Copyright 2005 S. Karger AG, Basel.)

Fallopian tube carcinoma is one of the rarest malignancies of the female genital tract. It is often diagnosed incidentally at an advanced stage. In recent years, an increase was observed in early stage fallopian tube carcinoma diagnosis. Such early diagnosis challenges the current FIGO staging system, as well as treatment recommendations, due to its limitations in precise discrimination between early stages. This is a case study of a 42 year-old woman, admitted for bilateral salpingo-oophorectomy due to bilateral ovarian cysts. Pathological examination incidentally revealed early staged fallopian tube carcinoma, which had invaded the lamina propria only, with no muscularis penetration. Due to the limited data regarding the efficacy of adjuvant chemotherapy at this early stage, only CA-125 levels follow-up was recommended.

Objective: To compare outcome in women undergoing termination of multiple pregnancy as compared with singleton pregnancy at 18-24 weeks' gestation by Laminaria dilatation and evacuation., Study Design: The medical records of 372 consecutive women undergoing does not increase pregnancy termination by Laminaria dilatation and evacuation at 18-24 weeks' gestation between January 1997 and December 2001 were reviewed and divided into a group with multiple pregnancies (38 cases) and a group with singleton pregnancies (334 cases). The 2 groups were then compared for differences in patient characteristics, indications for pregnancy termination and operative outcome. Statistical methods included Student's t and chi2 test., Results: Patients with multiple pregnancies were significantly older (P < .01), and a greater percentage of them were married (P < .001). The percentage of pregnancies following infertility treatment was also significantly higher in the group with multiple pregnancies (P < .0001). Furthermore, significantly more patients with multiple than singleton pregnancy underwent pregnancy termination due to preterm premature rupture of membranes (42.1% vs. 0.3%) (P < .00001), while significantly more singleton pregnancies were terminated due to structural and chromosomal fetal malformations (34.5% vs 10.6%) (P = .03). Operative outcome between the study groups differed mainly regarding blood transfusion; it was significantly greater in the group of patients undergoing multiple, as compared with singleton, termination (7.9% vs. 0.3%) (P < .00001). The group with multiple pregnancy had a longer hospital stay (1.7 +/- 0.9 vs. 1.2 +/- 0.5 days) (P < .001)., Conclusion: Termination of multiple pregnancies at 18-24 weeks' by dilatation and evacuation appears safe when performed by skilled surgeons. There is an increased need for blood transfusion.

Intravenous leiomyomatosis is a rare tumor described only in women, in which benign smooth muscle cells grow into the pelvic venous channels. The tumor may cause life-threatening symptoms if there is involvement of the inferior vena cava or the right atrium. This is a case study of intravenous leiomyomatosis with left ovarian extension in a 42 years old woman. The patient was admitted for total abdominal hysterectomy due to uterus myomatosus and menorrhagia. During the operation a frozen section was sent for examination revealing intravenous leiomyomatosis. Thereupon, bilateral salpingo-oophorectomy was also performed. This article reviews the cause, disease, presentation, diagnosis, treatment and recurrence of intravenous leiomyomatosis.

Background: We investigated whether hereditary thrombophilia is more prevalent in women with recurrent IVF-embryo transfer failures., Methods: This case-control study was conducted in an academic tertiary care hospital and compared 45 women with a history of four or more failed IVF cycles (group A) with 44 apparently healthy women matched for age and ethnic origin (group B). All participants were tested for inherited thrombophilias: mutations of prothrombin, factor V Leiden and methylene tetrahydrofolate reductase (MTHFR), and protein C, protein S and antithrombin III deficiencies., Results: Excluding homozygotic MTHFR, the incidence of thrombophilia in group A, was 26.7% compared with 9.1% in group B (P = 0.003; odds ratio 2.9; 95% confidence interval 1.02-8.4). The incidence of thrombophilia in women with unexplained infertility in group A was 42.9% (9/21), compared with 18.2% in group B (P < 0.002)., Conclusions: These data suggest that inherited thrombophilia may play a role in the aetiology of repeated IVF failures, particularly in the subgroup with unexplained fertility.