A Retrospective Review of the Outcome of Abdominal Myomectomies at a Fertility Centre in South-South Nigeria.

BACKGROUND: Abdominal myomectomy is a treatment modality for uterine fibroids. Its outcome depends on related variables which include the size, number and location of the fibroids, age of the patient, surgery and method used to secure haemostasis. OBJECTIVE: To determine the outcomes of abdominal myomectomies and related variables in a fertility centre in South-south Nigeria. METHODS: A retrospective study of the records of all cases of abdominal myomectomies performed between August 1, 2010 and July 31, 2017. Medical records of the 146 patients who had abdominal myomectomy during the period under review were retrieved and relevant data extracted. Information collected included the presence or absence of intra-abdominal adhesions, duration of tourniquet use, number and weight of enucleated fibroid seedlings, intraoperative blood loss, complications and the number of patients who achieved pregnancy after myomectomy. Data were analyzed using ANALYSE IT® statistical package. RESULTS: 146 patients underwent myomectomy during the period under review. The age range of the patients was 28-56 years (median 41 years). Almost all the patients (94.5%) had tourniquets applied to the uterus for hemostasis. The number of fibroids enucleated ranged from 1 to 154 and weighed between 0.02 and 2.8kg. Blood loss ranged from 100 to1500mls, 17.4% had post-operative fever, and one patient had bowel injury. Thirty-one patients (32.3%) who subsequently had in vitro fertilisation treatment achieved conception. CONCLUSION: Fibroids, weighing >0.5kg, are associated with increased blood loss during abdominal myomectomy, and a previous myomectomy significantly increases the risk of adhesions. Careful patient selection and meticulous surgical techniques are necessary to avoid morbidity in this setting with a high rate of large uterine fibroids.

RÉSUMÉ: La myomectomie abdominale est une modalité de traitement des fibromes utérins. Son résultat dépend de variables connexes qui incluent la taille, le nombre et l'emplacement des fibromes, l'âge du patient, la chirurgie et la méthode utilisée pour assurer l'hémostase. OBJECTIF: Déterminer les résultats des myomectomies abdominales et des variables associées dans un centre de fertilité du sud-sud du Nigéria. MÉTHODES: Une étude rétrospective des dossiers de tous les cas de myomectomies abdominales réalisées entre le 1er août 2010 et le 31 juillet 2017. Les dossiers médicaux des 146 patients ayant subi une myomectomie abdominale au cours de la période considérée ont été récupérés et les données pertinentes extraites. Les informations recueillies comprenaient la présence ou l'absence d'adhérences intra-abdominales, la durée d'utilisation du garrot, le nombre et le poids des plantules de fibromes énucléés, la perte de sang peropératoire, les complications et le nombre de patientes ayant obtenu une grossesse après myomectomie. Les données ont été analysées à l'aide du progiciel statistique ANALYZE IT®. RÉSULTATS: 146 patients ont subi une myomectomie au cours de la période sous revue. La tranche d'âge des patients était de 28 à 56 ans (médiane de 41 ans). Presque toutes les patientes (94,5%) avaient des garrots appliqués sur l'utérus pour l'hémostase. Le nombre de fibromes énucléés variait de 1 à 154 et pesait entre 0,02 et 2,8 kg. La perte de sang variait de 100 à 1500 ml, 17,4 % avaient de la fièvre postopératoire et un patient avait une lésion intestinale. Trente et une patientes (32,3%) qui ont eu par la suite un traitement de fécondation in vitro ont réussi à concevoir. CONCLUSION: Les fibromes, pesant > 0,5 kg, sont associés à une augmentation des pertes sanguines lors de la myomectomie abdominale, et une myomectomie antérieure augmente significativement le risque d'adhérences. Une sélection minutieuse des patientes et des techniques chirurgicales méticuleuses sont nécessaires pour éviter la morbidité dans ce contexte avec un taux élevé de fibromes utérins volumineux. MOTS CLÉS: fibrome, myomectomie abdominale, mesures des résultats.

Association of gynecological endoscopy surgeons of Nigeria (AGES) advisory on laparoscopic and hysteroscopic procedures during the COVID-19 Pandemic.

Coronavirus 2, or SARS-CoV-2 disease (COVID-19) is a global public health concern. Although there is a paucity of evidence to advise on the best practice, we recommend postponement of elective gynecological endoscopic surgeries until the pandemic is contained. Emergency surgeries should preferably be done through open surgeries than laparoscopy or hysteroscopy approach. However, if or when laparoscopy or hysteroscopy is considered, health personnel in theatre must wear appropriate personal protective equipment (PPE) and all standard precautions should be observed to prevent COVID-19 infection. When COVID-19 is highly suspected or confirmed, the patient should be referred to centers equipped in taking care of such cases.

Overview of Hysteroscopy.

Hysteroscopy involves the visualization of the endometrial cavity with the aid of a hysteroscope (Telescope) inserted through the cervix. Hysteroscopy can be performed in an office setting and minor pathologies managed. A distension medium is necessary for proper visualization. These media include gaseous media such as carbon dioxide, used for diagnostic hysteroscopy, and liquid based media such as normal saline and 1.5% glycine, used for both diagnostic and operative hysteroscopy. Complications following hysteroscopy are few. A hysteroscope should become part of the armamentarium of every gynaecologist.

Experience with the bonanno catheter in the management of OHSS from IVF-ET Cycles.

OBJECTIVE: To document our experience with the use of the Bonanno catheter as a closed abdominal drain for OHSS Methods: A retrospective study of all IVF embryo transfer (ET) treatment cycles carried out between May 2006 and April 2009 at a dedicated IVF centre. Case notes of patients with OHSS were retrieved and the outcome of the continuous closed abdominal drain with Bonanno catheter documented. RESULT: Within the period under review, 234 patients had controlled ovarian stimulation with ultrasound guided egg retrieval. Two hundred and twenty eight (228) got to the stage of embryo transfer with 72 clinical pregnancies. The clinical pregnancy rate was 31.58%. Fourteen (6%) of those who were stimulated developed OHSS and had a closed abdominal drain of the ascitic fluid using the Bonanno catheter. The average number of days of the abdominal drainage was 7.5days and the average volume of ascitic fluid drained from a patient per day was 2454.9 + 748mls. Eight (8) patients who had OHSS achieved clinical pregnancy (six intrauterine, one ectopic and one heterotopic pregnancies), giving a clinical pregnancy rate of 57.14% in patients with OHSS. Four patients had blocked Bonanno catheters and three of them had the catheter changed while the fourth had the catheter successfully flushed. Four patients had the insertion site dressing changed due to soaking with ascitic fluid. There was no incidence of injury to intra abdominal organs or broken catheter. CONCLUSION: Bonanno Catheter is both effective and safe in draining ascitic fluid following OHSS.

IVF Pregnancy and Delivery following Ultrasound Scan Guided Aspiration of a Left Hydrosalpinx- A Case Report.

The presence of hydrosalpinges is known to significantly reduce the pregnancy and implantation rates following in vitro fertilization (IVF). Salpingectomy or laparoscopic tubal occlusion before IVF have been shown to significantly improve pregnancy rates. Aspiration of the hydrosalpinges at the time of oocyte retrieval for IVF had been proposed as a viable alternative. We present a 36- year old nullipara with unilateral hydrosalpinx who declined salpingectomy prior to IVF treatment and subsequently had two failed IVF cycles. She however became pregnant with the third IVF attempt, following transvaginal ultrasound scan guided aspiration of the hydrosalpinx fluid at the time of oocyte retrieval. Large randomized trials are needed to clearly identify the place of ultrasound scan guided aspiration of hydrosalpinges on IVF outcome.

Comparison of IVF/ICSI outcome in patients with polycystic ovarian syndrome or tubal factor infertility.

BACKGROUND: One of the recognized treatment options for patients with polycystic ovarian syndrome (PCOS) is in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Fears are however sometimes raised concerning the likely outcome of treatment in such patients compared with their counterparts with tubal factor infertility. OBJECTIVE: To compare the IVF/ICSI performance in women with PCOS and those with tubal factor infertility. MATERIALS AND METHODS: A retrospective analysis. Case notes of 30 patients, 35 years and below, with PCOS and who underwent 33 IVF/ICSI cycles and those of 42 age-controlled patients with tubal factor infertility and who had 43 cycles between December 2004 and April 2008 were retrieved. Data including duration of down-regulation, dose of human Menopausal Gonadotropin (hMG), number of cancelled treatments, endometrial thickness, number of oocytes retrieved and fertilization rate, in addition to the number of embryos transferred with resultant pregnancy outcome were compared between the two groups. The main outcome measures were response to gonadotropin stimulation, fertilization rate and clinical pregnancy rate. RESULTS: There was no significant difference between the PCOS group and the tubal factor infertility group in the hMG dose (2.7 vs. 3.4 vials, respectively), endometrial thickness (10.5 vs. 10.1 mm, respectively) and embryos transferred (3.1 vs. 2.9, respectively). The fertilization rate was significantly higher in the tubal factor infertility group, which was 81.48% as against 63.24% for the PCOS group ( P < 0.0001). While more cases of ovarian hyperstimulation syndrome (OHSS) occurred in the PCOS group ( P = 0.049), overall clinical pregnancy rate per embryo transfer was similar (45.45% vs. 42.85%; P = 1), with similar miscarriage rates. CONCLUSION: IVF/ICSI performance in patients with PCOS is probably similar to their counterparts with tubal factor infertility with, however, a reduced fertilization rate and higher incidence of OHSS.

Ectopic pregnancy following in vitro fertilisation and embryo transfer.

BACKGROUND: ectopic pregnancy is one of the recognised complications of in vitro fertilisation (IVF) and embryo transfer. OBJECTIVE: to review cases of ectopic pregnancy following IVF at a fertility unit, with the aim of raising awareness towards its increased incidence and pattern of presentation. METHODS: case records of patients who had ectopic pregnancy following IVF over a three-year-period (July 2005-June 2008) were retrieved from the medical records department. Data including age, parity, risk factors for ectopic pregnancy as well as management modality were extracted and analysed. RESULTS: There were 64 clinical pregnancies during the study period. Of these, five were ectopic pregnancies, given a frequency of 7.8%. The minimum number of embryos transferred was two and maximum four. All the five cases had easy embryo transfer. There was one case of heterotopic pregnancy. Two (40%) patients had previous ectopic pregnancies with one having a third ectopic pregnancy despite previous bilateral salpingectomies. Four (80%) of the five cases had laparotomy done. Three (60%) cases had ruptured ectopic pregnancies. One case was managed conservatively with methotrexate. CONCLUSION: ectopic pregnancy can present following IVF procedures. A high index of suspicion is necessary even in cases with previous bilateral salpingectomies or easy embryo transfer.

Patients' preference for number of embryos transferred during IVF/ICSI: a Nigerian experience.

BACKGROUND: The Human Fertilization and Embryology Authority is considering limiting the number of embryos that can be transferred to single embryo per cycle as has been done in several European countries, with the aim of reducing the rate of multiple pregnancies and its attendant complications following in vitro fertilization (IVF) / Intracytoplasmic sperm injection (ICSI). OBJECTIVE: To determine the number of embryos patients' attending a fertility clinic in Nigeria, would prefer transferred during IVF/ICSI. MATERIALS AND METHODS: Fifty four consecutive female patients who underwent IVF/ICSI procedures between May 2006 and April 2007 at the Port Harcourt Fertility Centre, Rivers State were interviewed using structured questionnaires. They were informed of all the obstetric and perinatal complications of multiple pregnancies and the advantages and trend towards single embryo transfer and then asked to choose the number of embryos (one, two or three) they would prefer transferred assuming similar implantation rates. Each respondent was allowed to give reason(s) for their choice. DESIGN: Prospective, descriptive study. RESULTS: Fifty one (94.4%) of the respondents preferred the transfer of multiple (2 or 3) embryos. Only three (5.6%) patients opted for single embryo transfer. Majority of the patients (31 or 60.8%) preferred multiple embryo transfer because of their desire for twins while twenty (39.2%) cited cost of IVF as their reason. Fifteen (29.4%) patients saw multiple pregnancies as a compensation for their long periods of infertility. CONCLUSION: With the desire for twins and high poverty level in Nigeria, a policy of single embryo transfer might be difficult to implement. Health economic studies would be required to determine if the accumulative cost of taking care of twins/triplets is less, equal or outweighs the cost of several single embryo transfers.

Patients' Preference for Number of Embryos Transferred During IVF/ICSI a Nigerian Experience

Background: The Human Fertilization and Embryology Authority is considering limiting the number of embryos that can be transferred to single embryo per cycle as has been done in several European countries; with the aim of reducing the rate of multiple pregnancies and its attendant complications following in vitro fertilization (IVF) / Intracytoplasmic sperm injection (ICSI). Objective: To determine the number of embryos patients' attending a fertility clinic in Nigeria; would prefer transferred during IVF/ICSI. Materials and Methods: Fifty four consecutive female patients who underwent IVF/ICSI procedures between May 2006 and April 2007 at the Port Harcourt Fertility Centre; Rivers State were interviewed using structured questionnaires. They were informed of all the obstetric and perinatal complications of multiple pregnancies and the advantages and trend towards single embryo transfer and then asked to choose the number of embryos (one; two or three) they would prefer transferred assuming similar implantation rates. Each respondent was allowed to give reason(s) for their choice. Design: Prospective; descriptive study. Results: Fifty one (94.4) of the respondents preferred the transfer of multiple (2 or 3) embryos. Only three (5.6) patients opted for single embryo transfer. Majority of the patients (31 or 60.8) preferred multiple embryo transfer because of their desire for twins while twenty (39.2) cited cost of IVF as their reason. Fifteen (29.4) patients saw multiple pregnancies as a compensation for their long periods of infertility. Conclusion: With the desire for twins and high poverty level in Nigeria; a policy of single embryo transfer might be difficult to implement. Health economic studies would be required to determine if the accumulative cost of taking care of twins/triplets is less; equal or outweighs the cost of several single embryo transfers

The effect of endometrial thickness on in vitro fertilization (IVF)-embryo transfer/intracytoplasmic sperm injection (ICSI) outcome.

The value of measuring the endometrial thickness and studying the endometrial receptivity in the context of assisted conception remains a contentious issue. A prospective analysis was carried out to determine the effect of endometrial thickness on IVF - embryo transfer/ICSI outcome in dedicated Assisted Reproductive Technology (ART) units in Abuja and Rivers State, Nigeria. Two hundred and fifty one patients who met the inclusion criteria were analysed. They were grouped on the basis of endometrial thickness into 3 groups; <7 mm, 7 - 14 mm and >14 mm. The main outcome measure was clinical pregnancy. There were significantly more pregnancies in the 7 - 14 mm endometrial thickness group compared to the <7 mm and >14 mm groups, p=0.004 and p<0.0001 respectively. The findings suggest that following IVF/ICSI, significantly more pregnancies occurred when the endometrial thickness was between 7 and 14 mm.

Burden of domestic violence amongst infertile women attending infertility clinics in Nigeria.

BACKGROUND: Infertility affects about 20% or more of the population. Infertility can lead to domestic violence and any woman who experiences domestic violence because of infertility, has a double jeopardy. METHODS: This was a cross-sectional study involving 233 infertile women attending infertility clinics in 3 hospitals in Nigeria overa period of 12 months. RESULTS: Ninety seven (41.6%) of the women had experienced domestic violence because of their infertility state. The forms of domestic violence experienced were psychological torture 50 (51.5%), verbal abuse 38 (39.2%), ridicule 27 (27.8%), physical abuse 17 (17.5%) and deprivation 6 (6.2%). The main culprits were the husband 47 (48.5%) and female in-laws 31 (32%). Yoruba women were more likely to experience domestic violence than other tribes, although this difference did not reach statistical significance ( p > 0.05.) Educational level, parity, type of marriage and duration of infertility were not statistically significant (p > 0.05). CONCLUSION: In this setting, infertile women are prone to domestic violence. Prompt evaluation, counselling of the couple, as well as early treatment and prevention of infertility is necessary to avoid the problem and domestic violence. This should form part of efforts to meet the millennium development goals.