Does transvaginal hydrolaparoscopy render standard diagnostic laparoscopy obsolete for unexplained infertility investigation?

OBJECTIVE: To evaluate the feasability of transvaginal hydrolaparoscopy in infertile patients undergoing basic infertility investigations, and to determine its usefulness in comparison with standard laparoscopy. MATERIALS AND METHODS: Twenty-three unexplained infertile women were prospectively included. Selected patients had no history of pelvic disease or previous pelvic surgery and had normal findings on gynecological examination and vaginal sonography. The patients received general anesthesia and underwent the transvaginal hydrolaparoscopy immediately prior to a standard laparoscopy by a different operator. The main outcome measures were the rate of successful access to the pouch of Douglas, the duration of the procedure, and the rate of complications. In order to compare the accuracy of the transvaginal hydrolaparoscopy to the standard laparoscopy, findings in terms of tubal pathology, endometriosis, and adhesions were analyzed. RESULTS: The successful rate of access to the pouch of Douglas was 95.7%. The rate of complications was 4.3%. The mean duration of the transvaginal hydrolaparoscopy procedure was 8 min. The concordance between transvaginal hydrolaparoscopy and laparoscopy for pelvic cavity examination was statistically significant (k=0.57, P=0.02). In 40.9% of cases, the transvaginal hydrolaparoscopy procedure has shown a normal pelvic examination confirmed by laparoscopic diagnosis. According to the findings by laparoscopy, transvaginal hydrolaparoscopic diagnosis was correlated well in 81.8% of cases. When transvaginal hydrolaparoscopy showed pathological findings, there were no normal laparoscopies. Pathological laparoscopies were found in 18.2% of the normal transvaginal hydrolaparoscopies. CONCLUSION: The transvaginal hydrolaparoscopy is a reproducible and safe method to investigate the pelvis and its structures. The diagnostic accuracy of the transvaginal hydrolaparoscopy suggests that more than 40% of standard laparoscopies for unexplained infertility could be avoided.

Salpingectomy for repeated embryo nonimplantation after in vitro fertilization in patients with severe tubal factor infertility.

PURPOSE: To evaluate the impact of salpingectomy on the rates of embryo implantation and pregnancy in patients with severe, irreversible tubal factor sterility. METHODS: A retrospective study of patients with repeated failure of in vitro fertilization due to nonimplantation of the embryo. Seventy-two patients with severe and irreversible tubal factor sterility were selected following repeated failure of in vitro fertilization (IVF) due to assumed nonimplantation of the embryo: 35 underwent a salpingectomy before continuing IVF cycles and 37 continued IVF cycles without salpingectomy. RESULTS: After the first IVF cycle consecutive to diagnosis of embryo nonimplantation, the implantation rate was 10.2% in the salpingectomy group and 6.1% in the group without the procedure (P = 0.5). After all IVF cycles, the rate was, respectively, 6.9% and 4.5% (P = 0.2). Salpingectomy improved the pregnancy rate (PR) per transfer (23.5% vs. 9.9%; P = 0.01). The curves of the cumulative probability of becoming pregnant show that salpingectomy resulted in pregnancy more rapidly. CONCLUSIONS: Salpingectomy improves the PR per transfer in patients with severe and irreversible tubal factor sterility who have experienced repeated failure of IVF due to embryo nonimplantation. This procedure also reduces the number of IVF attempts needed to obtain pregnancy.

[Coasting: a response to excessive ovarian stimulation]. / Le coasting: une réponse à la stimulation ovarienne excessive.

The ovarian hyperstimulation treatment increases results of in vitro fertilization. However, the risk of ovarian hyperstimulation syndrome must be carefully evaluated for each patient. An excessive response increases complication and cancellation rates. Coasting could be applied when an excessive response occurred. This method requires stopping gonadotropin administration while GnRH agonist is continued. When the estradiol rate decreases, the hCG administration is allowed. In the literature, results shows adequate pregnancy rates, between 26 and 64%. It seems oocyte quality was not spoiled. However, coasting does not eliminate definitively the risk of ovarian hyperstimulation syndrome. Coasting method could be a safe and efficient method to treat an excessive ovarian response during in vitro fertilization protocol. Pregnancy rates seem to be preserved.

Randomized study comparing two techniques of conization: cold knife versus loop excision.

OBJECTIVE: To compare the histomorphologic and colposcopic results of cold knife conization and loop excision. METHODS: Sixty-six women were randomly allocated to have the cone specimen removed by cold knife excision (n = 38) or loop excision (n = 28). Subjects eligible for inclusion were those who presented histologically verified grade 3 cervical intraepithelial neoplasia (CIN) or grade 2 CIN with squamocolumnar junction not seen. RESULTS: The mean height of the cone specimens was greater in the cold knife group [18.9 mm (SD = 5. 5) and 12.8 mm (SD = 4.3), respectively; P = 0.0001], as was the frequency of clear margins (100 and 80%, respectively; P = 0.001). In the loop excision group, thermal injuries were present in half of the cone sections. The median (range) thickness of thermal injury was 0.98 mm (0-1.5 mm) in the ectocervix and 0.95 mm (0-1.75 mm) in the endocervix. Histologic evaluation of the endocervical margins was not possible in 2 cases (7%). At follow-up colposcopy, evaluation of the entire squamocolumnar junction was possible in 15 (39%) and 20 (71%) women, respectively (P < 0.01). Four patients in the cold knife group and 6 in the loop group had histologically confirmed persistent dysplasia (P > 0.05), yielding success rates of 90 and 79%, respectively (P > 0.05). CONCLUSIONS: Loop excision provides a sample that is adequate for histologic evaluation in most cases, results in the same success rate as cold knife conization, and allows optimal colposcopic surveillance in significantly more cases than cold knife excision.