Total Laparoscopic Hysterectomy for Endometriosis and an Arteriovenous Malformation.

STUDY OBJECTIVE: To show laparoscopic management of an arteriovenous malformation in a patient with deep pelvic endometriosis DESIGN: A step-by-step explanation of the surgery using an instructive video. SETTING: Hautepierre University Hospital, Strasbourg, France. INTERVENTIONS: We describe the case of a 37-year-old patient presenting with deep pelvic endometriosis and a uterine arteriovenous malformation. Deep pelvic endometriosis was diagnosed during a tubal ligation in 2015. Laparoscopy also showed some pelvic varicosities. Hysteroscopy was performed to increase the diagnostic precision. Huge blood vessels with an arterial pulse on the anterior wall of the uterus were found. The endometriosis of the patient was very symptomatic; she suffered from dysmenorrhea, menorrhagia, intense dyspareunia, and dyschezia. Magnetic resonance imaging indicated a large arteriovenous shunt in the anterior part of the uterus and bladder endometriosis. After a pluridisciplinary medical staff meeting, we decided to begin treatment with luteinizing hormone-releasing hormone analogs. Then, she underwent embolization of the arteriovenous malformation, which produced regression of the lesions as indicated by reevaluation with magnetic resonance imaging. We decided to perform laparoscopic hysterectomy. Evaluation of the abdominal cavity showed diaphragm endometriosis, deep pelvic endometriosis, and the arteriovenous malformation. We started with left ureterolysis and opening of the rectovaginal septum. After that, we radically dissected the left side of the uterus with a left oophorectomy and then the right side, conserving the ovary. Then, we shaved the bladder for endometriosis removal. To finish, we performed a right salpingectomy with a right ovariopexy, vaginal closure, and coagulation of the diaphragm's nodules. The patient agreed to record and publish the surgery, and the local institutional review board gave its approval. CONCLUSION: To conclude, preoperative embolization of the arteriovenous shunt improves surgery, avoiding excessive bleeding and permitting easier radical hysterectomy for deep pelvic endometriosis. Similar cases have been published [1], but to our knowledge, our video is the first regarding this subject. It appears that embolization can fail, but hysterectomy remains the gold standard treatment [2].

Luteal phase progesterone supplementation following induced natural cycle frozen embryo transfer: A retrospective cohort study.

INTRODUCTION: The objective of this study was to assess the impact on the clinical pregnancy rate of luteal phase progesterone treatment in patients being prepared for natural cycle frozen embryo transfer (FET) with induced ovulation. MATERIAL AND METHODS: This retrospective cohort study collect all the FET protocols over a 6-month period at Strasbourg University Hospital fertility unit between December 2016 and May 2017. In total 293 consecutive patients with regular menstrual cycles were prepared for natural cycle FET during this period. All patients had an embryo cryopreservation secondary to in vitro fertilisation (IVF) or by intracytoplasmic sperm injection (ICSI). There were 2 protocols during this period and patients either received or did not received progesterone. Ovulation was routinely triggered in all patients by injection of choriogonadotrophin alfa. Patients in the treated group received vaginal natural micronized progesterone treatment of 400mg daily, starting on the day of ovulation. The principal assessment criterion was the occurrence of pregnancy. RESULTS: In total, 231 patients were analysed: 108 in the group not receiving progesterone and 123 in the group receiving progesterone. Patient characteristics were comparable between groups. A higher clinical pregnancy rate (39% vs. 24.1%, p=0.02; 95CI [1.10; 3.74]) was recorded in the treated group. CONCLUSIONS: Our results suggest that luteal phase support with vaginal progesterone statistically increases the clinical pregnancy rate following hCG-triggered natural cycle FET and that it should be used more widely.