Endometriosis is a common inflammatory gynecological disorder which causes pelvic scarring, pain, and infertility, characterized by the implantation of endometrial-like lesions outside the uterus. The peritoneum, ovaries, and deep soft tissues are the commonly involved sites, and endometriotic lesions can be classified into three subphenotypes: superficial peritoneal endometriosis (PE), ovarian endometrioma (OE), and deep infiltrating endometriosis (DIE). In 132 women diagnosed laparoscopically with and without endometriosis (n = 73, 59 respectively), and stratified into PE, OE, and DIE, peritoneal fluids (PF) were characterized for 48 cytokines by using multiplex immunoassays. Partial-least-squares-regression analysis revealed distinct subphenotype cytokine signatures—a six-cytokine signature distinguishing PE from OE, a seven-cytokine signature distinguishing OE from DIE, and a six-cytokine-signature distinguishing PE from DIE—each associated with different patterns of biological processes, signaling events, and immunology. These signatures describe endometriosis better than disease stages (p < 0.0001). Pathway analysis revealed the association of ERK1 and 2, AKT, MAPK, and STAT4 linked to angiogenesis, cell proliferation, migration, and inflammation in the subphenotypes. These data shed new insights on the pathophysiology of endometriosis subphenotypes, with the potential to exploit the cytokine signatures to stratify endometriosis patients for targeted therapies and biomarker discovery.

A case is reported of early onset ovarian hyperstimulation syndrome (OHSS) after gonadotrophin-releasing hormone agonist (GnRHa) trigger for final oocyte maturation in a GnRH antagonist protocol. The use of GnRHa in place of HCG as a trigger for final oocyte maturation in an antagonist IVF cycle has been proposed as a method for preventing OHSS in predicted high-responders. This approach, however, did not prevent the occurrence of OHSS in our case despite a freeze-all strategy. To the best of our knowledge, this is a possible index case of severe OHSS with GnRHa trigger for oocyte maturation without any luteal HCG rescue for a high responder, despite IVF cycle segmentation.

Uterine leiomyomas are the most common tumours arising from the female reproductive tract. However, giant myomas, which are greater than 11.4 kg in weight, are exceedingly rare. They may cause a pressure effect on surrounding organs, heart and lungs, which can be potentially life threatening. We present a case of a 53-year-old woman with a massive uterine mass complicated by restrictive lung disease. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy with frozen section and reconstruction of the abdominal wall by the gynaecologists and plastic surgeons. The excised specimen weighed 27.8 kg, which included a benign subserosal leiomyoma measuring 64 by 50.5 by 15 cm. Intraoperative blood loss was 7 L and her postoperative recovery was complicated by coagulopathy and haemorrhagic shock. This case illustrates the pivotal role of multidisciplinary care in the management of complicated surgical patients and the need for careful perioperative care.

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Introduction: We aim to compare live birth rates, cost analysis and a survey of patient attitudes between laparosopic tubal re-anastomosis and IVF. Materials and Methods: Retrospective study: A retrospective study was done in a single reproductive medicine and IVF unit in Singapore, from January 2011 to December 2016. Previously ligated patients underwent either laparoscopic tubal re-anastomosis or IVF. The primary outcome was first live birth after treatment. Interval to first pregnancy, miscarriage and ectopic pregnancies were also reported. Survey: Patients attending the subfertility clinic completed a questionnaire on IVF and tubal re-anastomosis, on preferred choice of treatment, before and after reading an information sheet. Results: Retrospective study: 12 patients underwent tubal re-anastomosis while 31 patients underwent IVF treatment. Pregnancy (75.0% vs 35.5%) and live birth (58.3% vs 25.8%) were significantly higher in the tubal surgery group (P<0.05%) after transferring all available embryos in one stimulated IVF cycle. Cost per live birth was lower in the tubal surgery group (SGD27,109 vs SGD52,438). Survey: One hundred patients participated in the survey. A majority of patients preferred tubal surgery to IVF (68.2% vs 31.8%) before given information on the procedures, but indicated a preference for IVF (54.6%) to surgery (45.4%) after receiving information on the procedures. Conclusion: For women less than 40 years of age, desiring fertility after tubal ligation, laparoscopic tubal re-anastomosis offers better live birth rates and cost-effectiveness. Patients in Singapore are equivocal as to their preference after education regarding the choices. Thus laparoscopic tubal re-anastomosis remains a viable alternative to IVF treatment. Key words: Artificial reproductive technology, Laparoscopic tubal reversal, Previous tubal ligation