Reproductive outcome following hysteroscopic treatment of the septate uterus: a result of 28 cases at Ramathibodi Hospital.

We reported the reproductive outcome of 28 patients with septate uterus who underwent hysteroscopic metroplasty between August 1994 and October 1999 at Ramathibodi Hospital. The majority of septa were partial. Most of the patients had recurrent pregnancy losses. Division of the septum was performed with scissors in 7, a new device of Versapoint bipolar electrode in 10, and by means of resectoscope in 11 patients. The operating time varied from 45 to 70 minutes with an average time of 50+/-5.5 minutes which included the time for laparoscopy. The blood loss during the operation was minimal. All 28 patients were discharged a few hours after the operation. There were no serious complications attributed to this study. Most of the patients had minor spotting but no significant bleeding for a few days after hysteroscopic surgery. Of the 28 patients, 4 patients have not tried to conceive because of personal reasons, and the other 5 patients were lost to follow-up. Fifteen patients who had postoperative hysterosalpingograms, demonstrated a normal uterine cavity. There were a total of 20 pregnancies after a mean period of 24+/-1.4 (range 6-42) months following hysteroscopic treatment, of which 15(75.0%) were carried to term, 3(15.0%) were spontaneous abortions, and 2(10.0%) are in progress. The rate of pregnancy wastage in the post-treatment group was 15 per cent compared with 96.3 per cent in the pretreatment group.

Reproductive outcome following hysteroscopic lysis of intrauterine adhesions: a result of 65 cases at Ramathibodi Hospital.

We reported the reproductive outcome of 65 patients with varying degrees of IUAs who underwent hysteroscopic adhesiolysis between August 1994 and December 1996 at Ramathibodi Hospital. Of the 65 patients treated, 29 had mild adhesions, 26 had moderate adhesions, and 10 had severe adhesions. Adhesions were lysed with hysteroscopic scissors in 25, with biopsy forceps through hysteroscope in 10, with electrosurgery using a monopolar probe in 22 patients, and with resectoscope in 8 patients. The mean duration of the procedure was 15 +/- 2.1 minutes. The mean follow-up was 12 +/- 1.4 months. Of the 44 patients who originally presented with secondary amenorrhea, 40 (90.9%) have normal menses, 4 (9.1%) have hypomenorrhea. Of the 6 patients who had hypomenorrhea, 5 (83.3%) have normal menses. Cyclic abdominal pain disappeared after treatment in all patients. Of the 45 patients with IUAs and infertility, 16 (35.6%) conceived. Two (20%) of the infertile patients with initially severe adhesions conceived. Of the 5 patients with RPL treated, delivered a full term baby and the other delivered a premature baby at 29 weeks of gestation. All 18 patients who delivered, had live births. Adhesion reformation was absent in patients with initially mild and moderate adhesion but occurred in 2 out of 10 (20%) patients with severe adhesions. These two patients initially suffered from secondary amenorrhea but reported hypomenorrhea after surgery. Both of them had tuberculosis of the genital tract. There were no serious complications occurring in all 65 procedures. All 65 patients were discharged a few hours after the operation.

Hysteroscopic resection of submucous myoma: a result of 50 procedures at Ramathibodi Hospital.

We reported an initial result of the safety and efficacy of myomectomies performed between September 1994 and June 1997 by the hysteroscopic resectoscope in 50 patients at Ramathibodi Hospital. The indications for hysteroscopy and/or hysteroscopic myomectomy were menorrhagia in 23, metrorrhagia in 3, menometrorrhagia in 2, infertility with abnormal uterine bleeding in 12, abnormal uterine bleeding during hormonal replacement therapy (HRT) in 4, and suspected submucous myomas detected by ultrasonography and/or sonohysterography in 6 patients. The mean age of the 50 patients was 39.5 years with a range of 26 to 66 years. The sizes of the submucous myomas ranged from 1-5 cm. The mean of operation time was 32 minutes (range 15-60 minutes). The mean volume of 1.5 per cent glycine required for irrigation was 800 with a range of 600-2000 ml, and the mean deficit at the end of the operation was 300 with a range of 200-1000 ml. The mean estimation of blood loss during the operation was 80 ml with a range of 50-200 ml. Postoperatively 28 out of 30 patients with menorrhagia had improvement in excessive bleeding (93.33%). One patient underwent subsequent hysterectomy due to persistent heavy uterine bleeding from recurrent submucous myoma. All patients with infertility and patients under HRT had normal menstruation after this procedure. 2 out of 12 (16.67%) patients with infertility became pregnant after submucous resection. No serious complications occurred. One patient had a cervical laceration repaired by simple stitches. One patient had mild endometritis responding to outpatient antibiotics. Forty-eight patients were discharged from hospital the day after the operation, the remaining two staying overnight for observing post-operative bleeding. Our data suggested that resectoscopic myomectomy is a safe and effective surgical procedure. The procedure offers the advantage to the patients of a shorter hospital stay along with a low complication rate. The hysteroscopic approach to the symptomatic submucous myoma has dramatically changed the treatment options for patients who classically would be offered abdominal myomectomy or hysterectomy.

Diagnostic hysteroscopy: a result of 125 patients at Ramathibodi Hospital.

This report summarizes the diagnostic hysteroscopic experience with 125 selected patients. The procedures were all performed under propofol anesthesia. The main indications for diagnostic hysteroscopy were infertility with suspected intrauterine lesions and abnormal uterine bleeding in premenopausal women. The procedures were successful in 123 (98.4%) patients. Cervical dilatation was required in 35 (28%) patients. Of the 125 diagnostic examinations, 91 (72.80%) had intrauterine abnormalities. This result showed that an important factor that appears to influence the prevalence of pathology are the gynecological problems and/or symptoms of the patients. The commonest finding in patients with infertility was intrauterine adhesions, whereas, endometrial polyps was the most common finding found in premenopausal women with abnormal uterine bleeding. There was no complication attributable to this procedure. Our experience suggests that the efficacy and safety of this procedure depend on proper selection of patients, type of anesthesia, the medium for uterine distention, and most importantly the experience of the operator.

The influence of number of embryos transferred on pregnancy outcome in women undergoing in vitro fertilization and embryo transfer (IVF-ET).

The purpose of this study was to retrospectively examine the influence of number of embryos transferred on pregnancy outcome in women undergoing in vitro fertilization and embryo transfer (IVF-ET) between July 1990-December 1991 at the Royal Free Hospital, London, United Kingdom. This study included three groups of patients: group 1-the number of embryo used for transferring was one embryo, group 2-the number of embryos used for transferring was two embryos and group 3-the number of embryos used for transferring was three embryos. This study demonstrated that the clinical pregnancy rate increased significantly when transferring two or three embryos compared to one. But this rate did not differ significantly when two embryos were compared with three embryos. The multiple pregnancy rate, miscarriage rate, and ectopic pregnancy rate did not differ significantly among the three groups studied but there was a risk of higher order multiple pregnancy if more embryos were transferred. In this study we found 3 triplets out of 35 pregnancies when 3 embryos were transferred (Group 3). In conclusion, this study demonstrates that when two or three embryos were transferred the clinical pregnancy rate increased significantly. Transferring two embryos instead of three did not alter the pregnancy rate. Moreover, triplets pregnancies were eliminated. Therefore, we suggest limiting the number of embryos to be transferred at two and the supernumerary embryos should be cryopreserved for future transfer.

Effect of maternal age on clinical outcome in women undergoing in vitro fertilization and embryo transfer (IVF-ET).

The purpose of this study was to assess the effect of age of IVF success in women undergoing in vitro fertilization and embryo transfer by comparing IVF outcome in two groups of patients: group 1-age < or = 35 years old and group 2-age > 35 years old. This retrospective study covered a one year period between January 1991-December 1991 and included 230 patients with 634 treatment cycles. The patients' mean age was 32 +/- 1.9 (range 20-38 years old). Inclusion criteria for treatment of patients with IVF-ET included patients with tubal disease and non-tubal disease who have failed conventional treatments. The majority of patients had infertility from tubal damage, unexplained infertility, and male infertility. This study showed that all pregnancy rates, ongoing pregnancy rates and implantation rates were found to be higher in the < or = 35 year old group. The pregnancy rate per ET, ongoing pregnancy rate and implantation rate were found to be 35.17, 27.58, 16.53 per cent respectively; while in the > 35 year old group, the pregnancy rate per ET, ongoing pregnancy rate, implantation rate were found to be only 17.93, 11.03, 8.07 per cent respectively. The miscarriage rate tended to be higher in the > 35 year old group (34.62%) compared to 15.69 per cent found in < or = 35 year old group. Multiple pregnancy rate and ectopic pregnancy rate were found to be 17.65 and 5.89 per cent respectively for the < or = 35 year old group but only 7.69, 3.85 per cent respectively for the > 35 year old group. From the statistical analysis comparing the outcome of pregnancy in these two groups, the pregnancy rate per ET, implantation rate, ongoing pregnancy rate and miscarriage rate were found to have statistical difference with P < 0.05. However, multiple pregnancy rate and ectopic pregnancy rate did not show any statistical significance in these two groups (P > 0.05). In conclusion, the results of this study indicated that maternal age especially when greater than 35 years old adversely affects clinical pregnancy and the spontaneous abortion rate.

A comparative study between pelvic ultrasonography and laparoscopy in the detection of pelvic pathology in the initial workup of subfertile women.

This study was conducted prospectively from June 1992 to September 1993, we evaluated 115 patients attending our infertility clinic for the first time to determine the correlation between abdominal ultrasound and laparoscopy in the detection of pelvic pathology in the initial workup of subfertile women, depicting laparoscopy as the gold standard. Normal ultrasound scans were reported in 80 women (69.56% of total) 58 of whom had also normal pelvic findings at laparoscopy. The remaining 22 patients with normal ultrasound scans had abnormal laparoscopic findings in the pelvis giving a false negative rate of 27.50 per cent. These were primarily related to; endometriosis with adhesions (10), filmy adnexal adhesions (5), omental and bowl adhesions (5), and hydrosalpinx (2). Thirty five women (30.44% of the total) had abnormal scans. Pelvic pathologies were confirmed in 30 at laparoscopy. The remaining five had a normal pelvis (three retroverted uteri, and two functional ovarian cyst had disappeared at time of laparoscopy) giving a false positive rate of 14.29 per cent for ultrasound scans. Statistical analysis revealed that abdominal ultrasound scan in the detection of pelvic pathology in the initial workup of subfertile women has a sensitivity of 57.69 per cent, specificity of 92.06 per cent, positive predictive value of 85.71 per cent with negative predictive value of 72.50 per cent and accuracy rate of 76.52 per cent. We conclude that the use of abdominal ultrasound in the detection of pelvic pathology in the initial workup of subfertile women is not an appropriate routine screening test as it has low efficiency in detecting the pelvic pathologies many of which are the causes of infertility.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative study between scrotal physical examination and scrotal ultrasonography in the detection of varicocele in men with infertility.

From September 1989 to March 1991, we evaluated 110 men from our infertility clinic to determine the correlation between scrotal physical examination and scrotal ultrasonography in the detection of varicocele in men seeking clinical evaluation for infertility, depicting scrotal ultrasound as the gold standard. Of 110 men with infertility, clinically palpable varicocele was found in 40 patients (36.36%). Fifteen were of grade 1, nineteen of grade 2 and four of grade 3. Of these 40 patients, 32 (80%) had left sided varicocele 2 (5%) had right sided varicocele and the remaining 6 patients (15%) had bilateral varicoceles. Of the 40 patients with clinically palpable varicocele, 34 (85%) had the diagnosis confirmed by scrotal ultrasound. Of these 34 patients who had varicocele diagnosed by scrotal ultrasound, 17 (50%) had varicocele on the left side, 1 (2.94%) had varicocele on the right side and the remaining 16 patients (47.07%) had bilateral varicoceles. Seventy patients in whom initial scrotal physical examination failed to detect varicocele, 12 (17.14%) were found to have varicocele by scrotal ultrasound, all of which were on the left side. This group of patients was classified as subclinical varicocele. Statistical analysis revealed that scrotal physical examination in the detection of clinical varicocele has sensitivity of 73.90 per cent, specificity of 90.60 per cent and positive predictive value of 85.00 per cent with negative predictive value of 82.80 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective randomized crossover comparison of zygote intrafallopian transfer and in vitro fertilization-embryo transfer in unexplained infertility.

60 couples aged under 38 with unexplained infertility were recruited in this prospective randomized crossover study to compare the efficacy of treatment between ZIFT and IVF-ET. A total of 150 stimulation cycles were commenced and 132 proceeded to successful egg collection (88%). Fertilization successfully occurred in 114 cycles (86.36%). A total of 110 embryo replacements were carried out, (52 uterine transfer and 58 tubal transfer). This prospective randomized cross over trial demonstrated the trend for higher implantation rate, pregnancy rate, and ongoing pregnancy rate with ZIFT over IVF-ET for patients with unexplained infertility. The actual implantation rate, pregnancy rate, and ongoing pregnancy rate with ZIFT were 13.7, 34.5, 31.0 per cent respectively compared to the results from IVF-ET which were 12.1, 26.9, 25.0 per cent respectively. However, the difference was not statistically significant. Although this study showed a 5 per cent ectopic pregnancy rate with ZIFT and none with IVF-ET, the difference was not statistically significant. Similarly, there was no difference in the overall miscarriage rate and multiple pregnancy rate between the two protocols. In conclusion, this prospective randomized crossover trial demonstrated the trend for higher reproductive outcomes in term of implantation rate, pregnancy rate, and ongoing pregnancy rate with ZIFT over IVF-ET in unexplained infertility but the difference was not statistically significant.

Clinical applications of GnRH agonists in gynaecology.

There is no doubt that there is a wide range of clinical application for GnRH analogues within the field of Gynaecology. Both the indication and varying degree of suppression of the hypothalamic-pituitary-ovarian-axis are depicted in Table 3(34). This review focuses only on the use of GnRH agonist in the treatment of endometriosis, uterine leiomyoma, infertility in polycystic ovary syndrome and in IVF/GIFT programmes. In Thailand, this drug has achieved an important role in clinical therapy in just over the past few years and until now buserelin is the only preparation which is available.