Iranian Journal of Obstetrics, Gynecology and Infertility
Year:2005 | Volume:8 | Issue:2|Papers Count:25

Introduction and Objective: To compare the effects of the combination of aromatase inhibitor Letrozole (2.5 mg) and metformin vs. clomiphene citrate (CC; 100 mg) and metformin in clomiphene resistant PCO women.Materials and Methods: In a prospective randomized trial, a total of 120 cycles in 60 women with clomiphene resistant polycysytic ovary syndrome were studied. Patients were randomized into treatment with 2.5 mg of Letrozole daily (29 patients, 53 cycles) or 100 mg of CC daily (30 patients, 67 cycles). Number of mature follicles, endometrial thickness, estradiol level, pregnancy rate, and miscarriage rate were measured.Results: The mean age, BMI, infertility duration, ovulation rate and the number of mature follicles (>18 mm) in both groups of patients were similar.Total and per follicle estradiol concentrations were significantly lower in the Letrozole group than in the CC group on the day of HCG administration (1664.63± 1350 vs. 981.35± 648 and 783.38 ±251 vs. 447.60 ±133.36 picomol/L), and the endometrial thickness was significantly higher (0.82± 0.1 vs. 0.55 ±0.28 cm). No difference was found in metformin side effects between both groups. There was no significant difference in pregnancy rate between both groups. There was no significant difference in pregnancy rate between Letrozole and CC groups (10 cases or 34.5% vs. 5 pregnancies or 16.67% respectively). Two miscarriages of the 5 pregnancies (40.0%) occurred in the CC group with no abortion in Letrozole group. In comparison to the CC group term pregnancies were also significantly higher in the Letrozole group (10 cases or 34.5% vs. 3 pregnancies or 10.00% respectively).Conclusions: In women with clomiphene resistant polycysytic ovary syndrome, the combination of Letrozole and metformin is associated with higher pregnancy, and lower miscarriage rates in comparison to CC and metformin.

Regarding the importance of infertility, endometriosis is one of its important and curable causes. We have evaluated in this study the rate of occult endometriosis in infertile patients with unknown cause undergoing laparoscopy.We prospectively studied 58 patients with unexplained infertility who had been referred to Al-Zahra Hospital in a 12 month period (from Dec. 2001 to Dec. 2002) who underwent laparoscopy. Of 58 studied patients, 8(13.79%) had pathologically proven endometriosis. In laparoscopy, 4 cases (6.89%) had uterine myomatosis and in the others, uterus proved to be normal. 4 Patients (6.89%) had peritoneal adhesion, and adhesion of right adenexa was found in 8 (13.79%) and the left adenexa in 10 (17.24%), and posterior portion of uterine in 6 (10.34%). Two cases had posterior cul-de-sac fluid. In this study there was a significant relationship between dysparonia and adhesion of left adenexa, adhesion of posterior surface of uterine and fluid in cul-de-sac in laparoscopy (P=0.001, P=0.006, and P=0.027, respectively). Also, there was a significant relationship between galactorrea and peritioneal adhesion and adhesion of posterior surface of uterine and fluid in cul-de-sac (P=0.021, P=0.49, and P=0.004, respectively). In our study the prevalence of occult endometriosis was 13.79% that is in accordance with the previous researches, so in cases with unexplained infertility that do not respond to any treatment, one can immediately try to treat infertility with suspicion of probable occult endometriosis.

Introduction: Despite the high incidence of breast cancer and it’s high mortality and morbidity in the west, there was not an accurate survey on the types of breast pathologies in breast sample reports.Materials & Methods: In a descriptive survey of breast sample reports 2001-2004 in IRAN (Kermanshah), from 48,742 histo-pathologic reports, 904 reports were related to breast. The data from breast pathology reports were analyzed with descriptive statistics.Result: The most common age for patients with breast pathologies was 21-40 (52.1%). In 89.5% the samples were related to women and 10.5% to men.Fibroadenoma was the most common disorder reported in breast samples under 20 years old (52.3%), fibrocystic disease among 20-40 and breast malignancy among 41-60 (59.3%). Over age 60 also breast malignancy (41.9%) was the most common diagnosis. 1.20% of breast cancers were in men and other cases were in women. In 23.9% of women samples the diagnosis was breast malignancy. 34.35% of cases with malignancy were under age 40. Mean age of breast cancar was 45± 9. The most prevalant pathology in malignancies was invasive ductal carcinoma (52.7%).Conclusion: The mean age of breast cancer in our survey is lower than western reports and breast cancer under age 40 is more common. In future studies the cause must be evaluated. Malignancy in breast samples was 23.9%, That coordinates with western reports.

Introduction and Objective: One of the female problems, especially with aging and multiparity, is stress urinary incontinence. This can be treated with medical or surgical ways. Nowadays, minimal invasive techniques have some adherents. In this article we give the results of the I.V.S. technique.Materials & Methods: Since 2002 to 2004, 135 patients with S.U.I. referred to our clinic. 72 patients had S.U.I. and 21 had M.U.I. with S.U.I. prodominency. We did not do this procedure for patients with grade 2 or 3 cystocele. In brief, 14 patients 28-65 years old (average:42) were treated with I.V.S technique. 6 patients had the history of colporaphy because of S.U.I.. Before surgery we asked the patients for the history, ph.exm. and did routine exams, heart consult, renal and bladder sonography and P.V.R.. In lithotomy position and with local anesthesia we did cystoscopy and marshal test and if positive, under spinal anesthesia we did anterior vaginal incision from bladder neck to midurethra. Then we dissected mucous from under layer and perforated endopelvic fascia and release of the retropubic space and placed special tape in midurethra portion. Tension on the tape protected from leak at the time of the increased intra abdominal pressure or a little leak. After that we repaired vaginal mucosa and placed catheter and vaginal mesh. Patients had complete bed rest for 1 day, and we removed the catheter, and after that the patients voided.Results: There was no mortality in this procedure. In 1 patient the urethra was perforated, and we repaired it in 3 layers. Tape was placed replaced, and the catheter was in place for 10 days. There is no retention or dysparonia. In 1 patient we had U.T.I. that was treated with antibiotics. We did sonography and P.V.R. after 1 month that was less than upper limits of the normal in all r/patients.Conclusion: This technique is simple with short time anesthesia. We can use I.V.S. for 2 kinds of S.U.I. (hypermobility or I.S.D.) and this procedure is recommended for patients without cystocele or grade 1 cystocele because of low complications, good results, and effectiveness.

Introduction and Objective: Vaginal candidiasis is one of the most common genital infections, which has many different therapeutic methods. Some Para clinical researches suggest garlic for treatment of candidiasis. The purpose of this study was to compare the effect of garlic extract vaginal douche and clotrimazole vaginal cream in the treatment of women with vaginal candidiasis.Materials & Methods: This is a randomized, coutrolled, clinical trial on 100 non-pregnant women who came with the symptomatic vaginal candidiasis. Fresh garlic extract was provided by Pharmacologist, and then the patients whose mycologic culture was positive were randomly allocated in to 2 group of vaginal douche containing 1% garlic extract and vaginal cream containing 1% clotrimazole. All patients were treated daily for 7 days and assessed for clinical and mycological results 1-2 week after the end of treatment. Data were obtained by interview and observation methods and were analyzed by Spss software using Chi Square, Fisher exact test student t-test and paired- samples t-test by the confidence of 95%.Results: Successful response (according to clinical and mycologic results) were reported in 34.7% of Garlic users and 56.9% clotrimazole users. (P=0.026) There wasnot any significant difference between clinical results after treatment in both groups (51% against 66.7%) but there was a significant difference between mycologic results in both groups. (40.8% against 60.8%) (P=0.046)Conclusion: According to the results, percentage of successful response in users of vaginal garlic extract douche was less than users of vaginal clotrimazole cream but there was no significant statistical difference between these groups according to the clinical result. We suggest more studies about different methods and doses of this drug.

Introduction and Objective: Casarean section defined as a birth through a section from abdominal wall and uterus. In the US one of ten deliveries was performed in c/s. In the absence of complications, it is safer to allow a normal vaginal delivery than to perform a cesarean section. This research was performed to compare the complication after VBAC and repeat CS.Materials & Methods: 253 pregnant women with previous c/s attending the Mobini Hospital in Sabzevar were consecutively studied. Data gathered through these questionenires were analyzed.Results: Results showed that repeat CS increased the length of hospitalization (3.1 versus 1.2 day). Besides, complications were increased after surgery. In this study, there were no cases of uterin rupture in the VBAC group.Conclusion: According to these resalts with accurate selection of women and necessary care during labor, VBAC can used as a low risk technique.

Introductin and Objective: Preterm Labor increases the expenses of health costs. If it starts, there is no definite treatument. Some studies argue about prolonged starvation and Ramadan fasting in pregnancy with preterm Labor. This study is to clarify Ramadan fasting in pregnancy and preterm labor relation ship.Materials and Methods: Two-hundred and seventy preterm labors as case group and 966 term Labor controls are studied regarding Ramadan fasting in pregnancy. In 2003 fasting interval was about 12 hours.Results: Maternal age, parity, gravity, abortion and history of preterm labor was similar in two groups.One-hundred and nine (40.4%) out of 270 preterm labor cases were fasting in pregnancy and 161 (54.6%) were not. Three hundred and ninety eight (41.2%) out of 966 term labors were fasting and 568 (58.8%) were not. Ramadan fasting in pregnancy did not increase preterm labor probability (P:0.76).In the subgroup of Ramadan fasting in the first of pregnancy, fasting caused a decrease in preterm labor probability (p:0.000).Conclusion: About 12 hours Ramadan fasting in pregnancy dose not increase preterm labor probability.

Introduction and objective: Metformin, a biguanide antihyperglycemic drug, has been shown in improvement ovarian function and glucose metabolism in women with polycystic ovary syndrome (PCOS), but results concerning its effects on insulin sensitivity are controversial. ral contraceptive pills are commonly used in the treatment of PCOS; but like metformin, their influence on insulin sensitivity is not well known. The aim of this study was to compare of clinical improvement between Metformin and Diane in women with polycystic ovary syndrome.Materials & Methods: This research was a prospective randomized clinical trial study. We randomized 60 (20-49 years old) women with PCOS either to metformin (500 mg) X3 daily for 6 months or to ethinyl estradiol (35 microg) cyproterone acctate (2 mg) oral contraceptive pills (Diane) for 6 months. This study prolonged for 2 years.Results: Results showed that metformin significantly decreased the waist to hip ratio, body mass index (BMI), serum glucose and insulin concentrations and improved menstrual cyclicity, hirsutism score and Insulin sensitivity.Diane decreased hirsutism score and improvement in the menstrual pattern but slight effect in carbohydrate metabolism and increase serum glucose.Conculsion: Metformin, probably by way of its effects on adipose tissue, leads to reduction of hyperinsulinemia and concomitant improvement; in the menstrual pattern and clinical manifestation hyperandrogenism and therefore, it offers a useful alternative treatment for anovulatory women with PCOS. Dian slight incrased in fasting glucose, BMI and Waist To hip ratio but it is an effective treatment for women with hyperandrogenism and hirsutism.

Introduction: Preeclampsia is a common disorder in pregnancy which threatens maternal and fetus life. Hypertension disorders are the third major cause of maternal mortality. Oxidative stress has an important roll in pathophisiology of preeclampsia, and the toxicity of free radical oxygen is neutralized at presence of antioxidants such as vitamic C, E and β-carotene.Materials and Methods: In this case control study, 103 women with preeclampsia and 100 women with normal pregenancy have been studied during postpartum hospital stay. Food Frequency Questionnaire was completed by them, and their blood sample was collected in order to determine the concentration of intra leukocyte ascorbic acid. Data have been analyzed by using of statistical test such frequency student t-test, Mann Whiteny U, Pearson correlation coeficient and chi-square.Result: The daily mean number of fruit and vegetable consumption in control group was higher than the case group. However the difference between two groups was not significant. Only 17.5% of cases and 16% of controls consumed less than the recommended five servings of fruits and vegetables daily. The daily mean consumption of ascorbic acid in the case group was significantly lower than the control group (P=0.04). 18.4% of cases and 13% of controls consumed vitamin C less than the daily recommended value of 85 mg. The mean of level leukocyte ascorbic acid in the control was lower than case group. But the difference was not significant between two groups. In spite of weak correlation between leukocyte ascorbic acid level and vitamin C consumption in all of the study subjects and in the case group, significant positive correlation was observed in the control group (p=0.02, r=0.2).Discution: The increased mean of intra leukocyte ascorbic acid in case group can be due to the response to the oxidative stress of preaclamsia or can be caused by halting of ascorbic acid transfer from maternal blood to fetus or both of them. The weak correlation between intra leukocyte ascorbic acid density and the consumption of vitamin C may be produced by reasons which have been mentioned above or can be due to incorrect food production which it contains.According to these results, the consumption of foods which contain vitamin C, can prevent or control severity of preeclampcia in the pregnancy period.

Introduction & Objective: Planning in order to provide basic mental health for the couples during the pregnancy and post partum, requires an awarness of the situation of the existing psychological diseases among this group of society. This study aims at determining the mental health of women and their husbands during the pregnancy and postpartum.Materials & Methods: This research is a temporary, analytic and descriptive study in which a one-shot case study with 2 groups is used. The subjects consist of 100 couples selected simply and randomly from the representative samples. In order to collect the data, a form of personal characteristics, containing age, occupation, level of education, degree of pregnancy and agreement of couples with pregnancy and standard GHQ-28 questionnaires is used.Result: On the basis of achieved results, theout break rate mental disorders during of the first-mid of pregnancy among women and men is 25.7 percent and 24.4 percent, respectively. In the secondary-mid of pregnancy, the outbreak rate of mental disorders among women and men 47.9 and 39.9 percent, respectively. This rate of mental disorders among women and men is 36.4 and 35.7 percent, after pregnancy, respectively. These findings also represent that among the women and men studied, the most average scores of GHQ is due to depression domain, that is: (12.91± 1.52), (15.12± 4.81). according to achieved results, women in comparison with men meaningfully have achieved higher scores in subsets of depression symptom, disorder in performance, anxiety and physical symptoms.Conclusion: Regarding the high widespread of mental disorders among women and their husbands during the pregnancy and after it, more attention to mental supporting of couples during the pregnancy and postpartum, should be paid. These achieved results, the responsibility of decision-makers, healthy planners of country and the universities of medical-sciences more and more in relation to formulation of applied programs and implemention of mental health were revealed.

Objective: The aim of this study was to substitute measurement of 4 hour urinary protein instead of 24 hour urinary protein, which is the gold standard of proteinuria detection in patients with preeclampsia.Materials & Methods: This descriptive- cross sectional prospective study was conducted in two university hospital in Zahedan in the year 2004. 38 patients who were admitted due to preeclampsia and had 1+ or more proteinuria were studied. Each patient collected two urine samples: one was 4 hour urinary collection (from 8 o'clok to 12 mid day) and the other was 24 hour urinary collection (from 8 o'clok to 8 o'clok).Results: This study showed Pearson coefficient correlation for 4 hour urinary protein and 24 hour urinary protein was r= 0.96 (P<0.01).Conclusion: This study showed there is a direct correlation between 4 hour urinary protein and 24 hour urinary protein, and we can substitute the results of the former test for the latter.

Introduction and Objective: Presence and extent of axillary lymph node involvement are considered the most important prognostic factors for breast cancer. Removal of inadequate number of lymph nodes may lead to errors in the assessment risk of regional recurrence; distance metastasis and will adversely affect the treatment modalities. The aim of this study was to clarify the extent to which lymph node removal standards were utilized.Material & methods: in a cross sectional study; 116 patients who underwent modified radical mastectomy and axillary lymph node dissection in kerman hospitals for a period of 4 years (2001-2003) were reviewed.The pathology reports of these patients were obtained from pathology centers of hospitals and cancer registry of Kerman University of Medical Sciences, Social welfare Organization and private laboratories. Results: the mean number of nodes identified in the dissections was 10 (Range 2-36). In 63 patients (54.3%) the total number were less than 10 which showed a significant difference among pathologists.Conclusion: Regarding the high number of patients with unsatisfactory lymph node removal, use of standard methods such as fat clearing solutions are recommended.

Intrudoction & Objective: Preterm delivery is the leading cause for infants' mortality and morbidity after congenital anomalies. Because of its significance, it was decided to Carry out this Survey.Materials and Methods: 600 pregnant woman were assessed that 300 of them were patients with Preterm delivery and 300 of them were women with term delivery. The information gathered through interview and patient's medical record. Finally The resudts were Compared by chi square and T test statistical tests.Results: The prevalance of preterm delivery in Imam Reza hospital during this period (82.3.31- 81.10.1) was 16.4%.This evaluation showed a significan statistical difference between the preterm delivery and below factors mother's employment, mother's age, numbur of pregnaneies, history of preterm delivery in patient and in her first degree relatives, history of trauma, surgery and psychological Stress during pregnaney, vaginal bleeding and rupture and placenta previa, uterine anomalies, multiple pregnancies, cesarean section.There was no significant staistical differences between the preterm delivery and below factors: place of residence (city- village) the patient socieconomic status, mothor's height, smoking, addiction , prenatal care, patient's medical history, history of abortion and fetal death.Conclusion: Since many of predisposing factors for preterm labor are inevitable, once facing these factors, the process of preterm labor should be prevented. (by tocolytics). and in the case of inability to prevent labor mother should be transfer to a center where NICU is avaiable.

Introduction and Objective: Unwanted pregnancy is unplanned pregnancy.Researches show mother's concern to pregnancy health, nutrition and newborn's health was decreased, condition for women in low social economic status became worse, because of increased cost and facilities deficiency. If a child is the result of unwanted pregnancy, he is not physically and mentally healthy. Researches show 500,000 women died from complications of pregnancy in a world that 1/3 to 1/4 of them are reason for abortion due to unwanted pregnancy. Our aim for this study was to determine the rate of unwanted pregnancy and its related factors.Materials & Methods: 431 women referred to Lar and Grash Hospital for delivery or abortion were studied by data gathered in questionnaires from Sept 2003-Oct 2004.Results: Results show that unwanted pregnancy rate was 18.1% The main (44.5%) reason was financial factor. 21.7% of women werenot using any contraceptive method. The majority (43.6%) of them were using the contraceptive pill. Education, age, parity, contraceptive method, causes of unwanted pregnancy, birth of girl or boy was related to unwanted pregnancy, and chisequre test showed significant difference (p=000).Conclusion: Inside the health ministry the rate of unwanted pregnancy is high and women donot use contraceptive methods properly or donot use any contraceptive method. The most important reason of unwanted pregnancy was financial factor.

Objective: The aim of this study is evalution of clinical and histopathologic characteristics of patients with ovarian germ cell tumors.Materials & Method: In this descriptive retrospective study, we analysed 40 records of patients (<20 years) with ovarian germ cell tumor. The patients admitted and operated an in Imam Reza Hospital Mashhad from March 1981 to March 2001 (20 year period). Archival slides of all tumors were reviewed and tumors were classified according to the WHO system.Result: All of our patients were under 20 years with median age of 15.3 years, and the youngest was 13 months old.The prevalence of germ cell tumors (GCT) was 50.2% (40.79) of all ovarian neoplasms. From 40 patients with GCT, 26 cases (65%) were benign and 14(35%) were malignant.Mature cystic teratoma was the commonest neoplasm (26 patients). Of 14 children with malignant GCT, 9(22.5%) had pure dysgerminoma, 3(7.5%) had endodermal sinus tumor, and two (5%) had miexd malignant G.C.T. Unilateral involvment was seen in 38 cases (51.7% in right and 41.3% in left) and bilateral in two. Weight range of neoplastic ovarian lesion, were 15 (in endodermal sinus tumor) to 4200 gram (in mature treatoma). Tumoral torsion accounted for 2.5% (1 case) of our patients.Conculsion: Germ cell tumors are the most common ovarian neoplasms seen in the pediatric and adolescent age groups. Mature cystic teratoma and dysgerminoma are respectivly the most common benign and malignant G.C.T. Most patients with malignant ovarian germ cell tumor are in their reproductive years and wish to preserve fertility.

Objective: The aim of this research was accomplished by the objective of surving the effect of the group aerobic exercise program on the intensity of premenstrual syndrome in he female students who were residents of Kerman Open- University dormitory in 1381.Materials and Methods: This was a comparative clinical trial study on 58 students residing in the dormitory who were divided in two groups, experimental and control. Only the experimental group had 8 weeks of group Aerobic exercises.Data gathering instruments included were questionnaire, DASS21 criterion, premenstrual assessment from, step test and borg scale.Premenstrual syndrome intensity was determined and compared before and after management by utilizing t-test. Others used were K2 and two way variance analysis.Results: There was no significant difference between two groups regarding mean premenstural syndrome intensity before management (P=0.173) two groups were matched in age, BMI, areobic fitness systolic blood pressure…Findings showed after 8 weeks of management that mean P.M.S intensity was reduced in study group compared to previous management.Conclusion: Findings indicated that group aerobic exercise program decreased the intensity of premenstrual syndrome in subjects.

Introduction and Objective: Hemolytic diseases in fetal and newborn were known for years the principle of these pathologies is defined. Basically, entrance of fetal blood cells to maternal circulation results in these ranges of diseases. Risk factor determination, early diagnosis of F.M.H and adequate dosage of Anti- D Ig administration will be attempted to prevent subsequent adverse outcome on fetus and newborn. The quantification of fetal cells in the maternal circulation post- curettage miscarriage remains an important goal to prevent active immunization in mother.Materials & Methods: In this cross sectional study, during six months, from April 2004, one hundred patients post- abortion therapeutic curettage enrolled, in Ghaem Hospital, Mashhad University. Maternal age, gestational age, maternal blood group and Rh, gravidity, severity of maternal hemorrhage, HcT, BP and duration of vaginal bleeding were recorded. The KB test was done in all patients amount of F.M.H and Rh IgG dosage in positive KB patients were calculated. Data were analyzed with SPSS (Ver. 10) software.Results: The KB test was positive in 35% of the patient. Gestational age, maternal H.ct, pain and severity hemorrhage had significant relation to K.B test positive. F.M.H was 0.1-5 cc in 17 patients and in 18 was less.Conclusion: Lower gestational age in abortion time decreases FMH risk the usual Rh- IgG dosage (50 μgr) sounded to be adequate for Rh Immunization after post- abortion therapeutic curettage.

What: To improve care of patients with cancer.How: By setting standards of care, observing delivery of care, collection of data in regards to demography, diagnosis, evaluation, treatment, response, post treatment surveillance, rehabilitation, survival data, identification of deficiencies, education of medical, nursing and support personnel, evaluation of quality of care, research and publication of data.Who: Physician, administrator, data registrar.

Introduction and Objective: Turner Syndrome (TS) is the most common sex chromosomal abnormality. Patients (Pts) with TS are known to have higher incidence of congenital heart disease (CHD) than the general population. No studies have reported echocardiographic data according to the phenotype and chromosomal pattern in our country. The aim of our study was to assess an institutional experience.Materials & Methods: During 1995 to 2002, 37 unselected Pts with TS underwent cardiologic evaluation at the Imam-Reza Hospital. Karyotype distribution was: 45, X (65%), X-structural abnormalities (30%) and X-mosaism (50%).Results: The mean age at the time of dignosis was 12.81± 4.48 years. The prevalence of CHD was 21%. Coarctation of Aorta (CoA) was the most prevalent CHD. (Absolute and relative risk was 16% and 75% respectively) The Pts with 45, X karyotype had the greatest prevalence of CHD, and the PTS with X-mosaism showed no signs of CHD. The Pts with severe dysmorphic signs had 45,X karyotype and showed a significant higer relative risk of cardiac malformations.Conclusion: There is an absolute higher prevalence of CHD in Pts with TS. An accurate, periodic cardiologic evaluation is necessary in all Pts with TS.

Introduction and Objective: The intrauterine contraceptive device has been in use for many years, and migration of the device from the uterus to the pelvic cavity has been reported by many investigators. Although perforation of the uterus by an intrauterine contraceptive device is not uncommon, intravesical migration and secondary stone formation are rare complications. We report on a 35 years old woman in whom an intrauterine contraceptive device migrated from the uterus to the bladder and resulted in formation of a stone.

Introduction and Objective: Choriocarcinoma is the most malignant tumor of the gestational trophoblastic neoplasm. It grows rapidly and metastasizes to the lung, liver, brain, and less frequently to the other organs.Renal involvement is rare, however we encountered a female patient with metastatic choriocarcinoma of the both kidneys.Caser report: In this article a young woman with multiple metastases from choriocarcinoma is presented. She suffered from prolonged vaginal bleeding, permanent headache, and fever only five months after her first vaginal delivery. Investigation revealed uterus choriocarcinoma with multiple metastases to lung and liver, brain, and both kidneys. Our patient was treated with chemotherapy, radiotherapy and at the end of these treatment all metastases was cured.After a period of sixty month of treatment in serial follow-up, she is well with no sing of recurrent disease.