12.06.2014

Hcg test for ovarian cancer

Oshrit Lebovitz,Raoul Orvieto Gynecological Endocrinology. Fabio Cruz,Jose Bellver Gynecological Endocrinology. Patient information: See related handout on amenorrhea, written by the authors of this article. Primary amenorrhea can be diagnosed if a patient has normal secondary sexual characteristics but no menarche by 16 years of age. Endometrial regeneration using autologous adult stem cells followed by conception by in vitro fertilization in a patient of severe Asherman's syndrome. Newly emerging concepts in blood vessel growth: Recent discovery of endothelial progenitor cells and their function in tissue regeneration.
A novel five-transmembrane hematopoietic stem cell antigen: Isolation, characterization, and molecular cloning. Isolation and characterization of human CD34(-)Lin(-) and CD34(+)Lin(-) hematopoietic stem cells using cell surface markers AC133 and CD7.
Expression of VEGFR-2 and AC133 by circulating human CD34(+) cells identifies a population of functional endothelial precursors. Human neural stem cells differentiate and promote locometer recovery in spinal cord-injured mice. Intrauterine adhesions: Hysteroscopic diagnosis, classification, treatment and reproductive outcome. Expression of steroid hormone receptors, proliferation and apoptotic markers in primate endometrium.
In patients with primary amenorrhea, the presence or absence of sexual development should direct the evaluation. If a patient has no secondary sexual characteristics and no menarche, primary amenorrhea can be diagnosed as early as 14 years of age.
Many algorithms exist for the evaluation of primary amenorrhea; Figure 11,7,9,10 is one example. From adult autologous stem cells isolated from patient's own bone marrow, endometrial angiogenic stem cells were separated using immunomagnetic isolation. Constitutional delay of growth and puberty commonly causes primary amenorrhea in patients with no sexual development.
Secondary amenorrhea is the absence of menses for three months in women with previously normal menstruation and for nine months in women with previous oligomenorrhea. Laboratory tests and radiography, if indicated, should be performed to evaluate for suspected systemic disease. These cells were placed in the endometrial cavity under ultrasound guidance after curettage. Gargett Current Opinion in Obstetrics and Gynecology. Nguyen,Louie Ye Reviews in Endocrine and Metabolic Disorders. If the patient has normal pubertal development and a uterus, the most common etiology is congenital outflow tract obstruction with a transverse vaginal septum or imperforate hymen.


If the patient has abnormal uterine development, mA?llerian agenesis is the likely cause and a karyotype analysis should confirm that the patient is 46,XX. On development of endometrium with a thickness of 8 mm and good vascularity, in vitro fertilization and embryo transfer was done.
This resulted in positive biochemical pregnancy followed by confirmation of gestational sac, yolk sac, and embryonic pole with cardiac activity on ultrasound.
Endometrial angiogenic stem cells isolated from autologous adult stem cells could regenerate injured endometrium not responding to conventional treatment for Asherman's syndrome.
After pregnancy is ruled out, the initial work-up should be based on patient history and physical examination findings. This was followed by three cycles of superovulation with intrauterine insemination without success. She underwent IVF in June 2006, but did not conceive.She presented to us with infertility and scanty menstruation since her D and C. Her first transvaginal ultrasound scan on day 3 of the menstrual cycle revealed normal size retroverted uterus with homogenous myometrium and thin single line endometrium, but intact endometriomyometrial junction. A withdrawal bleed usually occurs two to seven days after the challenge test.3A  A negative progestogen challenge test signifies an outflow tract abnormality or inadequate estrogenization. Elevated follicle-stimulating hormone (FSH) or luteinizing hormone (LH) levels suggest an ovarian abnormality (hypergonadotropic hypogonadism).
Normal or low FSH or LH levels suggest a pituitary or hypothalamic abnormality (hypogonadotropic hypogonadism). After 6 months, the IUCD was removed.Ultrasound assessment of the endometrium in the following cycle showed no growth of the endometrium in the periovulatory and secretory phase of the menstrual cycle despite normal follicular development, rupture, and corpus luteum formation. She was given oral oestradiol valerate tablets in increasing doses from 4 mg daily for 3 days, followed by 6 mg daily for another 3 days, and then 8 mg daily for a total of 25 days along with aspirin 75 mg daily for endometrial preparation.
Ultrasound scans were done intermittently to assess the endometrium, but it never reached a thickness more than 3.6 mm.
This hormone replacement therapy cycle was repeated for 6 months without improvement of the endometrium.
Based on reports of adult autologous stem cells applications for regeneration of injured cartilage and cardiomyocytes in cardiac infarction, it was thought that use of stem cells for regeneration of endometrium was worth trying, especially because endometrium naturally has a regenerating capacity.
If the basal layer of the endometrium is repaired and further stimulated, it should increase in thickness.
This was the basis of this experimental therapy.The procedure was explained to the patient and her husband in March 2009. Possibilties of failure and risks of the procedure were also explained.On June 15, 2009, her bone marrow aspiration was done from the iliac crest under local anesthesia maintaining strict asepsis. Aspiration was done using bone marrow biopsy needle and 10 ml syringe prewashed with heparin. Collection was done in CPDA (Citrate-phosphate dextrose anticoagulant) medium using 1 ml of medium for 7 ml of bone marrow.
These cells were further treated by column separation technique and customized cocktail of CD9, CD90, and CD133 antibodies was used for immunomagnetic isolation of endometrial angiogenic stem cells. Gene expression study for CD9, CD44, and CD90 using RT-PCR technique was done for differentiated cells.


Total 39 million marker-positive endometrial angiogenic cells were supplied in 0.7 ml of PBS (phosphate buffer saline) with 2% autologous (patient's own) heat-inactivated serum on the next day for transplant. With patient in lithotomy position, Sim's speculum in place, anterior retractor was used to retract the anterior vaginal wall, and volsellum was used to hold the anterior lip of cervix. When the tip of the catheter was 0.5 cm below the fundus, piston was slowly advanced to allow slow steady flow of cell suspension in the uterine cavity. After instilling 0.3 ml of stem cell suspension at the fundus, injection was continued when cannula was gradually withdrawn out, till the tip reached mid cavity of the uterus.
It was further very gently and slowly withdrawn out of the internal os and then external os, maintaining continuous pressure on the piston to prevent any back flow. Speculum and volsellum were removed, and patient was shifted when she recovered from anesthesia.
She was discharged after 2 hours.She was given oestradiol valerate 6 mg daily, starting on the same day for 25 days.
After withdrawal bleeding, cyclical estrogen and progesterone therapy was repeated for four cycles. There were dominant follicles in either ovary, which excludes the possibility of any endogenous luteinizing hormone surge.
At this time, her endometrium was multilayered, with thickness of 7.1 mm and intraendometrial vascularity.
Anti-mullerian hormone, which is now considered to be the most reliable marker for ovarian reserve, was not routinely used at that time (2007) and was not easily available locally, and therefore was not done. Placement of IUCD after surgery and cyclical hormonal therapy in association with low-dose aspirin or nitroglycerine is an established protocol for development of functional endometrium. It is unknown whether these cells originate from bone marrow mesenchymal stem cells or, alternatively, are circulating endometrial cells originally derived from the endometrium and harbored in bone marrow. These cells, regardless of their origin, may serve as a source of reparative cells for the reproductive tract. These data show the potential for stem cells to have a role in the regeneration or repair of this tissue after injury. This was based on a study that describes that mononuclear cells collected from the menstrual blood contains a subpopulation of adherent cells and retains expression of the markers CD9, CD29, CD41a, CD44, CD59, CD73, CD90, and CD105; the markers used were CD9, CD44, and CD90 to isolate the desired cells. The risk for malignancies after the use of adult autologous stem cells may be a concern in view of several reports, but we would like to draw attention to the fact that most of these reports discuss the cases where adult autologous stem cells were used to treat malignancies. Larger studies can completely exclude this risk.The total cost of the therapy in an Indian set up comes to approximately Rs.
Moreover, it has an emotional and social advantage that the patient can bear her own child as against surrogacy.To the best of our knowledge, no case of Asherman's syndrome conceived after endometrial regeneration with adult autologous stem cells after failure of all other conventional modes of treatment has been reported in literature.
This therapy can be used as an alternative to surrogacy in females with severe Asherman's syndrome, though larger trials may be needed to establish this as proved line of treatment.



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