Vaginal Sonogram Research Articles

P-603 Viability of home monitoring of estrone-3-glucuronide (E1-3G) urine levels in controlled ovarian stimulation: A pilot study

Abstract Study question Can the regular determination of E1-3G levels in the patient's urine be used for successful monitoring of progestin-primed ovarian stimulation protocol (PPOS)? Summary answer Regular determination of E1-3G levels in urine can be successfully used in ovarian stimulation (OS), significantly reducing patient visits to the clinic. What is known already To reduce direct and indirect costs and to optimize the workload in IVF clinics, innovative approaches are being sought. It has only recently become possible to implement elements of telemedicine in OS monitoring. Patients have begun performing vaginal sonograms on their own. Studies have further shown that there is a close correlation in the growth of E2 in serum and E1-3G in urine during the menstrual cycle and ovarian stimulation. Thus, theoretical models for the use of urinary E1-3G in ovarian stimulation were developed, which are subject to experimental verification and analysis. Study design, size, duration This is a pilot study carried out in a clinic, which aims to establish the growth rate of E1-3G and to determine its upper and lower limits of growth on each consecutive day at which stimulation is adequate and safe. Inclusion criteria were patients aged < 40 years and AMH ≧ 1.1 ng/mL. From September to December 2022, in total 28 first ovarian stimulatiоn cycles from 28 infertility patients were included. Participants/materials, setting, methods A PPOS protocol with fixed doses of gonadotropins was used. From the second day of stimulation, the patients determined the E1-3G levels in their urine every day at home with a portable analyzer. In parallel, a standard ultrasound follow-up protocol was applied, accompanied by determination of E2, LH and P levels, in order to optimally control stimulation. Patients' convenience of this new approach was assessed using a questionnaire developed for the purpose. Main results and the role of chance The average female age was 32,1 years (±4.4), BMI 22,9 kg/m2 (±4,3), AMH 3,9 ng/ml (±2,7), stimulation days 10,1 (±1,2), collected oocytes 12,6 (±8,5), MII oocytes 10,8 (±7,9), fertilization rate 83,4% (±22,7), blastocyst formation 66,9% (±28,6), good quality blastocysts 31,1% (±16,6). The log-linear mixed effect model (LLMM) estimation produced reasonable estimates of 49% average day-to-day growth rates (slope fixed effect), with one standard deviation (SD) range of 25% to 77% across patients (SD of the slope random effect). Moreover, there was a comparatively high correlation of 0.76 between the individual growth rates of E1G estimated over days 3-6 (the slope random effects of the LLMM model) and the E1-3G levels at day 10. In this way, the estimated slope random effects appear to have a prognostic value and may potentially have therapeutic implications, for example, adjustment of the stimulation dose. Moreover, the Spearman correlation between Estradiol and E1-3G was 0.83 After analyzing interviews and questionnaires, patients evaluated the applied method as easy and convenient, with 97% of them preferring OS monitoring to be performed in this manner compared to the standard method, which includes regular ultrasound examinations and determination of serum hormone levels. Limitations, reasons for caution The small statistical sample size is a limitation of this study, which was carried out in a single clinic. The results have to be confirmed in other clinics and with more diverse populations. Wider implications of the findings This is the first study to analyze the dynamics of E1-3G in the PPOS protocol and the limits of its increase during the entire OS. The results confirm our theoretical model for the successful use of urinary E1-3G in OS. The method is easy to apply and well-accepted by patients. Trial registration number N/A

Babies, Bodies, and Buyers

In the thirty-five years since I began my career in legal education, much about the status of women, gender and sexuality has changed. There are the obvious triumphs: more female students, faculty and deans--as well as more bathrooms for more kinds of people than just "men." Life is less lonely now, and conversation more intersectional. There is more openness about LGBT issues. There is marriage equality, however contested. And there is less general tolerance for open forms of harassment. But challenges remain. While reproductive rights have always been at the center of women's work in the academy, that conversation has changed in complex ways in recent years--in no small part because of revolutionary new assisted-reproductive and genetic technologies. From oosplasmic transfer (1) to pre-implantation genetic diagnosis (2) to the precise gene-editing capabilities of Crispr-cas9, (3) these technologies can facilitate quiet forms of eugenic natalism. Increasingly, consumerist rather than dignitary notions of choice have been deployed to chase non-medical, cosmetic notions of human perfectibility. I worry that this shift signals an ever-more pervasive styling of bodies--including future bodies--as private property, and as inert clay-for-the-molding. I am hardly alone in my concern that the ultra-contractarianism of our neo-liberal moment is not such a good thing when it dominates all crannies of human endeavor. Its narrowed understanding of corporeal integrity compromises many of the erstwhile goals of public accommodation for all. Below are three stories in which the personal is short-circuited as exclusively private rather than politically expressive as well. The first story is about surrogate pregnancy--by now a comparatively old-fashioned technology of assisted reproduction, but one rife with the ethical challenges and cultural incoherence to which I allude. In late January of 2014, Kansas State Senator Mary Pilcher-Cook introduced a bill that would have criminalized the use of surrogate contracts in pregnancy and imposed a $10,000 fine and up to a year in jail for anyone participating in such a transaction. (4) The effort was quickly abandoned amid a blizzard of publicity that included pro-lifers battling pro-lifers; Republicans battling Republicans; invocations of God having hired the Virgin Mary as a surrogate; vaginal sonograms broadcast live in a Senate committee; and by a host of other posturing too easily dismissed as risible. (5) If the bill hadn't been body-slammed into the dust by some of the sillier assertions of its chief proponent (Pilcher-Cook asserted, for example, that surrogacy creates children that are "not going to have either a biological mother, biological father or both" (6)), the discussion might have garnered more attention. The laws regarding surrogacy are a national jumble of inconsistent public policies, extra-legal technological engineering, free-market contracting, civil interventions, and criminal sanctions. However incoherent the Kansas attempt, there was a serious question at its center: whether individually-drafted private contracts are sufficient to settle questions of intended parenthood, or whether the "best interests of the child" standards governing custody, adoption, and other realms of family law should have greater sway. While some states have long found surrogate contracts not in the public interest, at least ten already criminalize them. (7) Many of those laws were passed in the very early days of ovum transplantation and have not been reviewed in the decades since. Hence, what laws are in place have not nearly kept up with the explosive technological revolution in assisted reproduction. Even in states that purport to regulate, it is largely doctors and IVF technicians who call the shots as to what's acceptable in the realm of surrogacy and reproductive techniques. (8) There is deep conceptual confusion, as well as outright conflict, about what is at stake in surrogacy. …

An Unusual Case of Acute Hepatitis in a Pregnant Woman

Viruses, such as Epstein-Barr virus (EBV) may affect the liver, with hepatic injury that can range from mild and transient elevations in aminotransferases to acute and even fulminant hepatitis. Since EBV is a rare causative agent of hepatitis, the demographics, clinical features and outcome are not completely understood. A 22 year old female with no past medical history presented to the Emergency Room due to jaundice since seven days prior to evaluation. Skin discoloration was preceded by a prodrome of fatigue, general malaise, headaches, retro-orbital pain, nausea, vomiting, anorexia and myalgia. Patient denied sick contacts, or recent travel and immunizations were up to date. She had no history of smoking or alcohol, and no family history of liver disease. Physical exam showed lymphadenopathy and icteric sclera. Laboratories showed an AST of 946 U/L, ALT of 957 U/L, AlkPhos of 339 U/L, GGT of 212 U/L, total bilirubin level of 4.56 mg/dL with direct bilirubin at 3.23 mg/dL. Quantitative beta-hcg was positive at 3,039 mIU/ml; and last menstrual period and vaginal sonogram confirmed intrauterine pregnancy at 5 WGA. Findings were suggestive of acute hepatitis in pregnancy. Patient was admitted for further workup and supportive measures. Abdominal ultrasound with Doppler examination revealed no evidence of parenchymal liver disease or biliary obstruction or vascular thrombosis. HIV, RPR, ANA, ASMA, AMA and serum and urine toxicology were negative. Patient was also tested serologically for acute and chronic viral hepatitis including hepatitis A, B, C, E, EBV and Cytomegalovirus (CMV); showing evidence of past Hepatitis A infection, immunity to Hepatitis B, and positive for Epstein Barr Viral Capsid IgM Antibody. After several days of conservative therapy, liver enzymes and physical examination showed improvement and patient was discharged home. This case illustrates the clinical presentation of EBV hepatitis in a pregnant woman, causing self-limiting hepatitis. Since the clinical presentation may be indistinguishable between the various forms of viral hepatitis, a high index of suspicion is required in the adequate clinical setting, to allow for prompt recognition, treatment and avoid long term complications.

Salivary estradiol as a surrogate marker for serum estradiol in assisted reproduction treatment

IntroductionControlled ovarian hyper-stimulation for in vitro fertilization or intra cytoplasmatic sperm injection necessitates close monitoring using ultrasound and estradiol measurements. Monitoring is also important to prevent or limit the severity of ovarian hyper stimulation syndrome, an iatrogenic and potentially life-threatening complication. Self-operated endovaginal telemonitoring has been shown to offer an attractive and less costly alternative to classic consultation and saliva estradiol measurements could be a stress-free and practical alternative to serial blood determinations. Objectives were to evaluate whether saliva can be a surrogate marker for serum estradiol and its potential applicability in assisted reproduction treatment monitoring. Material and methodsSerial blood and saliva samples were collected from 31 patients undergoing ovarian hyper-stimulation. All patients were followed-up using in-house serial vaginal sonograms and immunoassay serum estradiol measurements. Afterwards estradiol was determined in saliva and serum by LC-MS/MS. For a subset equilibrium dialysis and measurement of free serum estradiol was performed. ResultsAbout 1% of estradiol is present in serum in its free, unbound, form. Salivary estradiol correlates well to both serum free estradiol and serum total estradiol (r=0.80). The concentration of salivary estradiol corresponds to the unbound concentration in serum. The dynamics observed in serum monitoring during treatment are closely mimicked in saliva. ROC analysis on the current limited dataset suggested a saliva cut-off of 22pg/mL (81pmol/L) could help predict risk for OHSS. ConclusionsSalivary E2 can be considered a surrogate marker for free serum estradiol and total serum estradiol in assisted reproduction treatment. Additionally there might be a role as a prediction marker for OHSS although this finding has to be validated in larger datasets.

Babies, Bodies, and Buyers

In the thirty-five years since I began my career in legal education, much about the status of women, gender and sexuality has changed. There are the obvious triumphs: more female students, faculty and deans--as well as more bathrooms for more kinds of people than just men. Life is less lonely now, and conversation more intersectional. There is more openness about LGBT issues. There is marriage equality, however contested. And there is less general tolerance for open forms of harassment. But challenges remain. While reproductive rights have always been at the center of women's work in the academy, that conversation has changed in complex ways in recent years--in no small part because of revolutionary new assisted-reproductive and genetic technologies. From oosplasmic transfer (1) to pre-implantation genetic diagnosis (2) to the precise gene-editing capabilities of Crispr-cas9, (3) these technologies can facilitate quiet forms of eugenic natalism. Increasingly, consumerist rather than dignitary notions of choice have been deployed to chase non-medical, cosmetic notions of human perfectibility. I worry that this shift signals an ever-more pervasive styling of bodies--including future bodies--as private property, and as inert clay-for-the-molding. I am hardly alone in my concern that the ultra-contractarianism of our neo-liberal moment is such a good thing when it dominates all crannies of human endeavor. Its narrowed understanding of corporeal integrity compromises many of the erstwhile goals of public accommodation for all. Below are three stories in which the personal is short-circuited as exclusively private rather than politically expressive as well. The first story is about surrogate pregnancy--by now a comparatively old-fashioned technology of assisted reproduction, but one rife with the ethical challenges and cultural incoherence to which I allude. In late January of 2014, Kansas State Senator Mary Pilcher-Cook introduced a bill that would have criminalized the use of surrogate contracts in pregnancy and imposed a $10,000 fine and up to a year in jail for anyone participating in such a transaction. (4) The effort was quickly abandoned amid a blizzard of publicity that included pro-lifers battling pro-lifers; Republicans battling Republicans; invocations of God having hired the Virgin Mary as a surrogate; vaginal sonograms broadcast live in a Senate committee; and by a host of other posturing too easily dismissed as risible. (5) If the bill hadn't been body-slammed into the dust by some of the sillier assertions of its chief proponent (Pilcher-Cook asserted, for example, that surrogacy creates children that are not going to have either a biological mother, biological father or both (6)), the discussion might have garnered more attention. The laws regarding surrogacy are a national jumble of inconsistent public policies, extra-legal technological engineering, free-market contracting, civil interventions, and criminal sanctions. However incoherent the Kansas attempt, there was a serious question at its center: whether individually-drafted private contracts are sufficient to settle questions of intended parenthood, or whether the best interests of the child standards governing custody, adoption, and other realms of family law should have greater sway. While some states have long found surrogate contracts in the public interest, at least ten already criminalize them. (7) Many of those laws were passed in the very early days of ovum transplantation and have been reviewed in the decades since. Hence, what laws are in place have nearly kept up with the explosive technological revolution in assisted reproduction. Even in states that purport to regulate, it is largely doctors and IVF technicians who call the shots as to what's acceptable in the realm of surrogacy and reproductive techniques. (8) There is deep conceptual confusion, as well as outright conflict, about what is at stake in surrogacy. …

Successful laparoscopic surgery of abdominal pregnancy: report of a case

Case Report: A 35-year-old woman who had 3 years infertility period was referred to our hospital because of suspected ectopic pregnancy. A halo surrounded by a thin hyperechoic area, which was suspicious for ectopic pregnancy, was visualized by vaginal sonogram in the right adnexal region and laparoscopic surgery was performed. A 10 x 10 x 10 mm dark blood mass was observed on the left side of peritoneum of vesico-uterine pouch. There was no other findings suggesting ectopic pregnancy anywhere in pelvis. Neovascularity was minimally observed close to the mass and it was resected with adjacent peritoneum after the injection of a dilute vasopressin solution around the mass. The blood loss was little. Operative findings fulfilled Studdiford's criteria of primary peritoneal pregnancy. Villus, decidua and peritoneum were observed in the same specimen. The postoperative course was uneventful and serum hCG level was declined rapidly. It may be possible to manage abdominal pregnancy on laparoscopic surgery without suffering from profuse bleedings, if the diagnosis was established in early pregnancy.

Postmenopausal hormone therapy increases use of health services: Experience from the Estonian Postmenopausal Hormone Therapy Trial [ISRCTN35338757

This study was undertaken to compare utilization of health services and health care costs in a randomized hormone therapy trial. A total of 1823 healthy postmenopausal women aged 50 to 64 years at the time of sampling were allocated to combined continuous hormone therapy or placebo or no treatment. The analysis was based on routinely collected electronic data in the Estonian Health Insurance Fund database during a follow-up period from 2 to 5 years. In the nonblind subtrial, the number of all health care visits was 10% higher and the number of visits to family practitioners 16% higher per person-year in the hormone therapy arm. Per person-year, the number of vaginal sonograms was 14% and the number of electrocardiograms 19% higher in the nonblind hormone therapy arm. Outpatient health care costs and drug expenses were higher in the nonblind hormone therapy arm. In the blind subtrial, the number of gynecologic operations, vaginal sonograms and total health care costs was higher in the hormone therapy arm. Hormone therapy caused additional expenses on health care.

Poster 170: Abdominal Pain: An Unusual Presentation of Thoracic Disk Herniation—A Case Report

Setting: Community hospital. Patient: A 41-year-old white women with acute left lower quadrant (LLQ) pain. Case Description: The patient without prior injury developed a severe and disabling LLQ pain 5 days ago for which she was admitted to the hospital for further evaluation. She rated her abdominal pain 8/10, which was not controlled by her medication regimen of oxycodone (OxyContin) and oxycodone/acetaminophen (Percocet). Workups, including routine labs, abdominal computed tomography scan, pelvic and vaginal sonogram, and intravenous pyelogram, were significant only for a urinary tract infection, which was treated with antibiotics.

Placental site trophoblastic tumor in a patient with secondary infertility and radiological findings consistent with a leiomyoma: a case report

Placental site trophoblastic tumor (PSTT) is the rarest form of gestational trophoblastic diseases. We report a 40-year-old woman who presented initially after a year of secondary infertility with prolonged menstrual flow. Her last pregnancy ended in a suction dilation and curettage at 8 weeks' gestation for a missed abortion. A hysterosalpingogram revealed a solid 5 × 4.5 cm filling defect impinging on the endometrial cavity suggestive of a submucosal leiomyoma. A vaginal sonogram confirmed the findings. The patient underwent a laparotomy for excision of the 5-cm friable, necrotic mass that was performed by curetting. Pathologic examination of the specimen revealed sheets of intermediate trophoblastic cells characterized by large polyhedral cells and positive human placental lactogen staining consistent with PSTT. The patient eventually underwent total abdominal hysterectomy 4 weeks later with no evidence of residual tumor on histologic examination.

Effect of the Yuzpe regimen of emergency contraception on markers of endometrial receptivity.

This exploratory study was designed to determine whether treatment with the Yuzpe regimen of emergency contraception altered endometrial integrin expression or other markers of uterine receptivity. Nineteen parous women were followed for two menstrual cycles. In the second cycle, each participant took 100 mg ethinyl oestradiol and 1 mg norgestrel on the day of the urinary luteinizing hormone (LH) surge and repeated the dose 12 h later. In both cycles, endometrial biopsy, phlebotomy and vaginal sonogram were performed 8-10 days after the urinary LH surge. No significant difference was found between untreated and treated cycles in most measures of endometrial histology or in endometrial expression of beta3 integrin subunit, leukaemia inhibitory factor, glycodelin, or progesterone receptors assessed by immunohistochemical techniques. Five statistically significant changes were noted in treated cycles: a reduction in endometrial MUC-1 expression, an increase in endometrial oestrogen receptor, lower luteal phase serum oestrogen concentration, reduced endometrial thickness, and greater proportion of glandular supranuclear vacuoles. The relationship of these findings to the contraceptive action of the Yuzpe regimen is unclear.

Improved demonstration of endometrial polyps and submucous myomas using saline-enhanced vaginal sonohysterography

We evaluated the efficacy of enhancing the vaginal ultrasound visualization of endometrial polyps and submucous fibroids using intrauterine saline as a contrast medium in 30 women with abnormal uterine bleeding. Each woman underwent evaluation with a standard vaginal sonogram and then a saline-enhanced sonogram. For the latter, sterile saline was instilled into the uterine cavity with a soft polyethylene, intrauterine insemination cannula to enhance the visualization of intrauterine structures. The patients subsequently underwent hysteroscopy and endometrial sampling. The saline-enhanced vaginal sonohysterogram clearly improved the visualization of submucous myomas and endometrial polyps in 17 of 19 women. In four women it showed no evidence of myomas or polyps. In seven of the earlier procedures in this series, filling of the uterine cavity was too poor to use the results. We conclude that vaginal saline sonohysterogram is simple yet safe, and is a valuable preoperative diagnostic procedure.

Distal ureteral calculi: detection with vaginal US.

To describe the use of vaginal ultrasonography to identify distal ureteral calculi and hydroureter. Abdominal and vaginal sonography were performed in 13 women with distal ureteral calculi. Indications for sonography included flank pain, hematuria, and suspected appendicitis. Six patients were pregnant. In each patient, vaginal sonograms demonstrated a distal ureteral calculus; in only two cases was the calculus detected with transabdominal sonography. Distal hydroureter was identified with vaginal scanning in each patient but with abdominal scanning in only two. Hydronephrosis was absent in three patients, mild in six, and moderate in four. Symmetric ureteral jets were noted at transabdominal sonography in two of nine patients. Follow-up transvaginal scans obtained shortly after passage of stones in two patients revealed swelling of the trigone but normal ureteral jets. In symptomatic female patients, use of vaginal sonography should be considered to evaluate the distal ureter for calculi, particularly if the results of transabdominal examination are normal or inconclusive.

Screening for fetal anomalies during the first trimester of pregnancy: transvaginal versus transabdominal sonography.

Ultrasound is a sensitive tool for the diagnosis of fetal anomalies during the prenatal period. Most knowledge about the ultrasound images of such anomalies is based on abdominal scanning during the second trimester of pregnancy. The value of transvaginal sonography for evaluating fetal anomalies and a comparison with transabdominal sonography in the first trimester has, to our knowledge, so far not been studied. During a 12-month period, 800 pregnant women between 9 and 13 weeks of gestation, underwent first a transabdominal scan followed by a transvaginal examination, in order to compare the value of the two techniques. Eight cases of fetal abnormality, including anencephaly, exencephaly, cervical myelomeningocele, cystic hygroma, omphalocele, posterior fossa cyst and syndactyly, were diagnosed by using the transvaginal sonographic approach. The standard abdominal technique failed to detect four of these anomalies, while in the other four only vague and non-specific fetal abnormalities could be demonstrated. All women with normal abdominal and vaginal sonograms in the first trimester were rescreened transabdominally at mid-gestation. Five patients with a variety of fetal anomalies, including hydrocephalus, agenesis of corpus callosum, bilateral ureteropelvic junction obstruction, right heart hypoplasia and tetralogy of Fallot, were identified in the rescreening procedure. One case of ventricular septal defect and coarctation of the aorta was not detected at either of the first or second screening procedures. Our findings show that transvaginal sonography is more sensitive than transabdominal sonography in the detection of first-trimester anomalies. However, since not all fetal anomalies are manifest so early in pregnancy, standard abdominal sonography in the second trimester is still recommended.

Assessment of the late proliferative phase endometrium by ultrasonography in patients undergoing in-vitro fertilization and embryo transfer (IVF/ET)

This study reports on 330 women aged 29 to 45 years, who underwent 411 cycles of in-vitro fertilization and embryo transfer (IVF/ET). Vaginal sonograms were performed during the late proliferative phase of natural cycles and cycles of controlled ovarian hyperstimulation (COH) with gonadotrophins, to evaluate both the thickness and echogenicity of the endometrium. Findings classified as Grade I; characterized by homogeneous echogenicity of the endometrium, and Grade II; characterized by an outer peripheral layer of dense echogenicity surrounding a central sonolucent area (i.e. a 'halo pattern'). Grades I and II were subclassified on the basis of thickness into A (greater than or equal to 9 mm) and B (less than 9 mm). Grade IIA ('optimal') was associated with a clinical pregnancy rate per embryo transfer of 33% while Grades IA, IB and IIB ('poor') were associated with a rate of only 7%. Women aged 41-45 years experienced a 25% incidence of 'poor' sonographic grades while the incidence in women less than or equal to 40 years of age was 5%. The presence of various uterine pathologies was associated with 'poor' endometrial grades in 86% of cases while only 11% of normal uteri manifested 'poor' grades. 'Optimal' endometrial grades in natural cycles were consistently associated with 'optimal' grades in ensuing cycles of COH (96%). Women with 'poor' endometrial grades in natural cycles improved in 55% of cases during subsequent COH. The results of this study indicate that sonographic assessment of the endometrial lining in the late proliferative phase during both natural and COH cycles is a valuable method for screening and managing IVF/ET candidates.

Transvaginal sonography as a screening method for ovarian cancer a report of the first 1000 cases screened

From November 1987 to April 1989, 1000 women 40 years or older underwent screening vaginal sonography at the University of Kentucky Medical Center (Lexington, KY). Patients included in this investigation were all asymptomatic and had no known pelvic abnormalities. Each ovary was measured in three planes and ovarian volume was calculated using the prolate ellipsoid formula. The upper limit of normal for ovarian volume was 18 cm3 in premenopausal women and 8 cm3 in postmenopausal women. In patients with normal scans, mean ovarian volumes decreased from 6.8 cm3 to 3.0 cm3 with menopause. Thirty-one patients (3.1%) had abnormal vaginal sonograms and 24 underwent exploratory laparotomy. All patients undergoing surgery had ovarian or fallopian tube tumors with dimensions identical to those predicted by ultrasound. Histologic diagnoses of these tumors included the following: adenocarcinoma, one, serous cystadenoma, eight; endometrioma, six; and cystic teratomas, two. Vaginal sonography was performed easily and without complications, and was well accepted by patients. All patients with normal sonograms have been rescreened annually and none have subsequently developed ovarian cancer. Further clinical trials to determine the efficacy of vaginal sonography as a screening method for ovarian cancer are indicated.