Minimal Access Surgery Unit, Division of Gynaecologic Endocrinology and Reproductive Medicine, University Department of Obstetrics and Gynaecology, General Hospital of Vienna, Waehringer Guertel 1820, A-1090 Vienna, Austria
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Abstract |
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Key words: in-vitro maturation/laparoscopy/polycystic ovary syndrome
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Introduction |
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Anovulation and infertility are the predominant problems in the majority of women with PCOS, and this explains why the principal aim of different treatment protocols is restoring ovulation. Medical regimens such as clomiphene citrate and conventional high-dose gonadotrophins are often unsuccessful and accompanied by a high prevalence of ovarian hyperstimulation syndrome (OHSS). In this clinical situation, laparoscopic ovarian drilling using monopolar current has been proven to be highly successful, resulting in ovulation rates of up to 90% (Gjonnaes, 1994). Another fascinating approach has reported successful pregnancies achieved from in-vitro matured (IVM) oocytes retrieved transvaginally from unstimulated, anovulatory patients with PCOS (Chian et al., 1999
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Case report |
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To initiate the IVM treatment cycle, she was given 10 mg dydrogesterone (Duphaston; Solvay Duphar BV., Weesp, Holland) twice daily for 10 days to get a regular menstrual cycle. Following withdrawal uterine bleeding, a complete hormone profile was taken on day 3 (LH: 13.8mU/ml; FSH: 6.0 mU/ml; androstenedione: 5.66 ng/ml; testosterone: 0.92 ng/ml; estradiol: 38 pg/ml; progesterone: 0.39 ng/ml; prolactin: 9.8 ng/ml), and baseline transvaginal ultrasonography (right ovary with 12 follicles, all <6 mm in diameter; left ovary with 15 follicles, all <6 mm in diameter) was performed. Scans were repeated on day 6 (right ovary with 12 follicles, all <7 mm in diameter; left ovary with 14 follicles, all <6 mm in diameter), day 8 (right ovary with 12 follicles, all <7mm in diameter; left ovary with 14 follicles, all <7 mm in diameter) and day 10 (right ovary with 12 follicles, all <8 mm in diameter; left ovary with 14 follicles, all <7 mm in diameter) to exclude the development of the dominant follicle. On day 12 the patient was given 10 000 IU HCG (Pregnyl; Organon, Oss, Holland), and laparoscopy was performed 35 h later (day 14). Immature oocytes were aspirated using a specially designed needle (Cook IVF, Queensland, Australia) placed in the middle of the lower abdomen. Subsequently, ovarian electrocautery was carried out using a monopolar needle (40 watts) at the puncture sites of oocyte retrieval. Sixteen oocytes were aspirated from both ovaries and collected in 10 ml culture tubes (Falcon, Franklin Lakes, NJ, USA) containing a maturation medium [diluted mixture Medi-Cult universal IVF medium (Medi-Cult, Jyllinge, Denmark)] plus 75 IU HMG per 10 ml (Menogon; Ferring, Kiel, Germany). Grouped oocytes were cultured as cumulus cells in Nunc 4-well dishes, 0.5 ml maturation medium per well (without oil) for 24 h. Eleven oocytes reached metaphase II, one oocyte reached metaphase I, four oocytes were degenerated, and routine ICSI was performed on each. Fertilization of seven oocytes (64%) was assessed 16 h later by the appearance of two distinct pronuclei and two polar bodies. A total of three 2-cell embryos were transferred 48 h after ICSI, and the remaining four embryos were cryopreserved. For endometrial preparation and luteal support, the patient received one daily dose of 2 mg estradiol (Progynova; Schering, Berlin, Germany) starting at the day of oocyte retrieval and 400 mg of progesterone administered vaginally starting at the day of ICSI respectively.
Two weeks after the embryo transfer the urinary pregnancy test was positive and after another 2 weeks the serum ß-HCG level was 3850 IU/ml, and an ongoing singleton pregnancy with a fetal heartbeat was confirmed at transvaginal ultrasound examination. In October 2000 the patient had a normal vaginal delivery, the female baby weighing 3180 g. Of note, to date (April 2001) the patient has had two regular menstrual cycles, a recent transvaginal ultrasound revealed completely normal ovaries, and the hormonal profile showed no abnormalities compared with the pre-operative findings.
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Discussion |
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Notes |
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Submitted on January 1, 2001; resubmitted on June 8, 2001
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References |
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Franks, S. (1995) Polycystic ovary syndrome. N. Engl. J. Med., 333, 853861.
Gjonnaes, H. (1994) Ovarian electrocautery in the treatment of women with polycystic ovary syndrome (PCOS). Acta Obstet. Gynecol. Scand., 73, 407412.[ISI][Medline]
Homburg, R. (1996) Polycystic ovary syndromefrom gynaecological curiosity to multisystem endocrinopathy. Hum. Reprod., 11, 2939.[Abstract]
Mikkelsen, A.L., Smith, S.D. and Lindenberg, S. (1999) In-vitro maturation of human oocytes from regularly menstruating women may be successful without follicle stimulating hormone priming. Hum. Reprod., 14, 18471851.
accepted on October 8, 2001.