Emergency Obstetric Hysterectomy after Conservative Management of Placenta Accreta.

Background: Obstetric hemorrhage is a frequent and life-threatening complication of either vaginal or cesarean delivery. It can be due to many causes, one of which is placenta accreta, the abnormal invasion of the placenta into the myometrial wall of uterus. Ultrasonography is the first line diagnostic method that can lead to the diagnosis of placenta accreta although, the depth of penetration is estimated by magnetic resonance imaging. Placenta accreta is a life-threatening situation requiring an experienced health care team for its management. Hysterectomy is usually performed although, conservative management might be preferred in carefully selected cases. Case Presentation. A 32-year-old woman (G2, P0) who had an inconsistently monitored pregnancy appeared at a regional hospital with contractions at 39th week of gestation. In her first pregnancy, she was subjected to cesarean section due to delay in second stage of labor and unfortunately her child died due to sudden cardiac death. During C-section, placenta accreta was identified. Given her previous history and her desire to maintain fertility, conservative management was initially planned to preserve her uterus. However, due to persisting vaginal bleeding immediately after delivery an emergency hysterectomy was performed. Conclusion: Conservative management of placenta accreta can be considered in some special cases with the aim to spare fertility. However, if bleeding cannot be controlled during the immediate postpartum period, emergency hysterectomy is unavoidable. A specialized multidisciplinary medical team is required to optimize management.

Successful conservative medical management of an interstitial ectopic pregnancy at 10 weeks of gestation: A case report.

BACKGROUND: Interstitial pregnancy is a rare type of ectopic pregnancy, accounting for 2-6% of ectopic pregnancies, but it can be life threatening. There is no clear consensus on management, either surgical or medical, and it depends on hemodynamic stability and whether fertility-sparing treatment is requested. CASE PRESENTATION: We present the case of a 35-year-old woman (G2, P1) who was diagnosed with an interstitial pregnancy at 10 weeks of gestation following in vitro fertilization. She was hemodynamically stable and requested fertility-sparing treatment. She was managed successfully with methotrexate and folinic acid with a hospital stay of 17 days. CONCLUSION: Interstitial pregnancy can be managed medically. However, these patients require close monitoring.

Exogenous retroelement integration in sperm and embryos affects preimplantation development.

Retroelement transcripts are present in male and female gametes, where they are typically regulated by methylation, noncoding RNAs and transcription factors. Such transcripts are required for occurrence of retrotransposition events, while failure of retrotransposition control may exert negative effects on cellular function and proliferation. In order to investigate the occurrence of retrotransposition events in mouse epididymal spermatozoa and to address the impact of uncontrolled retroelement RNA expression in early preimplantation embryos, we performed in vitro fertilization experiments using spermatozoa preincubated with plasmid vectors containing the human retroelements LINE-1, HERVK-10 or the mouse retroelement VL30, tagged with an enhanced green fluorescence (EGFP) gene-based cassette. Retrotransposition events in mouse spermatozoa and embryos were detected using PCR, FACS analysis and confocal microscopy. Our findings show that: (i) sperm cell incorporates exogenous retroelements and favors retrotransposition events, (ii) the inhibition of spermatozoa reverse transcriptase can decrease the retrotransposition frequency in sperm cells, (iii) spermatozoa can transfer exogenous human or mouse retroelements to the oocyte during fertilization and (iv) retroelement RNA overexpression affects embryo morphology and impairs preimplantation development. These findings suggest that the integration of exogenous retroelements in the sperm genome, as well as their transfer into the mouse oocyte, could give rise to new retrotransposition events and genetic alterations in mouse spermatozoa and embryos.

Open versus closed oocyte vitrification system: a prospective randomized sibling-oocyte study.

Vitrification has been successfully applied in the cryopreservation of oocytes and embryos. It can be achieved either by direct (open system) or indirect (closed system) contact with liquid nitrogen. Unlike embryo vitrification, few reports have been published regarding oocyte vitrification in closed systems. In order to validate the effectiveness of a closed and aseptic vitrification approach for oocyte cryopreservation, a prospective, randomized study was performed. Sibling oocytes donated from the same donor were randomly and equally assigned into closed or open vitrification groups. A total of 75 vitrification-warming cycles were performed in each group. Apart from the survival rate (82.9% versus 91.0%, P<0.05), no statistically significant differences were observed in pregnancy (ß-human chorionic gonadotrophin positive) (42.7% versus 33.3%), clinical pregnancy (36.0% versus 28.0%), implantation (13.8% versus 10.1%), ongoing pregnancy (33.3% versus 24.0%) and live birth (36.0% versus 24.0%) rates between the closed and open groups, and 27 and 18 healthy babies were born, respectively. This study shows that the replacement of the open vitrification system by a closed system has no impact on clinical pregnancy and implantation rates. Therefore, the closed vitrification system provides an aseptic alternative to the open method for oocyte vitrification.

Synergistic effect of follicle-stimulating hormone receptor and androgen receptor gene variants on semen quality.

Follicle-stimulating hormone (FSH), interacting with its receptor (FSHR), participates in the production of spermatozoa and androgens. Androgens exert their effects on male sex determination, development and sperm production by binding to androgen receptor (AR). In the present study, we sought to explore the potential synergistic effects of FSHR and AR gene variants on sperm quality. 200 oligozoospermic and 250 normozoospermic men were examined. DNA was extracted from spermatozoa, and the FSHR 307 (T/A), FSHR 680 (N/S) and AR (CAG)n polymorphisms were genotyped. Their parallel analysis revealed six combined genotypes. A gradual reduction of sperm motility, from long AR allele-Thr307Thr/Asn680Asn carriers to long AR allele-Ala307Ala/Ser680Ser carriers and from short AR allele-Thr307Thr/Asn680Asn carriers to short AR allele-Ala307Ala/Ser680Ser carriers was revealed in normozoospermic men (P < 0.001). Similar associations were observed in oligozoospermic men (P < 0.001). In our series, the synergism of the long AR alleles with the FSHRThr307/Asn680 allelic variant was associated with increased sperm motility, while the synergism of the short AR alleles with the FSHRAla307/Ser680 allelic variant was associated with decreased motility, supporting the significance of these genes in semen quality.

Semen quality is influenced by androgen receptor and aromatase gene synergism.

STUDY QUESTION: Does synergism between AR(CAG)(n) and CYP19(TTTA)(n) polymorphisms influence the quality of sperm? SUMMARY ANSWER: AR(CAG)(n) and CYP19(TTTA)(n) polymorphisms had a synergistic effect on sperm concentration and motility. WHAT IS KNOWN ALREADY: Androgens exert their action in the testicular tissue by binding to androgen receptor (AR), while their action is mediated by the aromatase P450 enzyme (CYP19). AR(CAG)(n) alleles are associated with sperm motility and CYP19(TTTA)(n) allelic variants have implications for sperm concentration and motility. STUDY DESIGN, SIZE, DURATION: Two hundred oligozoospermic and 250 normozoospermic men who presented for infertility investigation were examined during a period of 2 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: Conventional semen analysis was performed. DNA was extracted from spermatozoa and both polymorphisms were genotyped by polymerase chain reaction. Serum hormone levels were determined. MAIN RESULTS AND THE ROLE OF CHANCE: Six combined genotypes were identified between the 18 AR(CAG)(n) alleles with 12-32 repeats and the 6 CYP19(TTTA)(n) alleles with 7-12 repeats. A gradual reduction in the sperm concentration (10(6)/ml) and motility (%) from long AR allele-non-CYP19(TTTA)(7) allele carriers to long AR allele-CYP19(TTTA)(7) homozygotes and from short AR allele-non-CYP19(TTTA)(7) carriers to short AR allele-CYP19(TTTA)(7) homozygotes was observed in normozoospermic men (means ± SD; concentration: 93 ± 53.1 versus 65 ± 48.6 and 85 ± 60.1 versus 37 ± 17.2l, P < 0.002; motility: 63 ± 10.3 versus 55 ± 14.5 and 52 ± 19.6 versus 41 ± 13.7, P < 0.001, respectively). Similar associations were observed in oligozoospermic men (concentration: 10 ± 4.2 versus 9 ± 5.9 and 10 ± 6.3 versus 6 ± 3.1, P < 0.03; motility: 47 ± 17.1 versus 39 ± 6.2 and 39 ± 22 versus 27 ± 18.3, P < 0.003, respectively). The above associations of the combined genotypes with sperm concentration and motility were confirmed in the total study population (P < 0.006 and P < 0.001, respectively). LIMITATIONS, REASONS FOR CAUTION: Our study population was limited to Greek Caucasian adult males, residents of Northwest Greece. WIDER IMPLICATIONS OF THE FINDINGS: The confirmation of our findings in other populations would verify the significance of AR and CYP19 genes for spermatogenesis. STUDY FUNDING/COMPETING INTERESTS: This study did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector. The authors declare no conflicts of interest.

Dramatic reduction in sperm parameters following bariatric surgery: report of two cases.

Severe obesity constitutes the main public health crisis of the industrialised world. Bariatric surgery has been proposed as the most efficient treatment of obesity. In this study, we report the potential effects of bariatric surgery on semen parameters in male partners of couples undergoing assisted reproduction. These patients had been tested in the context of infertility treatment in two consecutive cycles before and after bariatric surgery. A marked reduction in sperm parameters was observed in a period of twelve to eighteen months after surgery. This unfavourable effect had also remarkable effects on the assisted reproduction outcome, necessitating the counselling of patients before bariatric surgery.

Low-dose HCG may improve pregnancy rates and lower OHSS in antagonist cycles: a meta-analysis.

Human chorionic gonadotrophin (HCG) may substitute FSH to complete follicular growth in IVF cycles. This may be useful in the prevention of ovarian hyperstimulation syndrome. Relevant studies were identified on Medline. To evaluate outcomes, a meta-analysis of low-dose HCG-supplemented IVF cycles versus non-supplemented ones was performed with data from 435 patients undergoing IVF who were administered low-dose HCG in various agonist and antagonist protocols and from 597 conservatively treated patients who served, as control subjects. Using these published data, a decision analysis evaluated four different management strategies. Effectiveness and economic outcomes were assessed by FSH consumption, clinical pregnancy and incremental cost-effectiveness ratios. Clinical pregnancy and ovarian hyperstimulation were the main outcome measures. Nine trials published in 2002-2007 were included. From the prospective studies, in the gonadotrophin-releasing hormone antagonist group, a trend for significance in clinical pregnancy rate was evident (odds ratio [OR], 1.54; 95% confidence interval [CI], 0.98-2.42). Ovarian hyperstimulation was less significant in the antagonist low-dose HCG protocol compared with the non-supplemented agonist protocol (OR 0.30; 95% CI 0.09-0.96). Less FSH was consumed in the low-dose HCG group but this difference was not statistically significant. Low-dose HCG supplementation may improve pregnancy rates in antagonist protocols. Overall, low-dose HCG-supplemented protocols are a cost-effective strategy.

Evidence for association of sex hormone-binding globulin and androgen receptor genes with semen quality.

The roles of androgen receptor AR(CAG)n gene polymorphisms and sex hormone-binding globulin SHBG(TAAAA)n gene polymorphisms on semen quality were studied. One hundred fourteen men were included in the study: 85 with normal sperm count and 29 oligospermic. The genotype analysis, on DNA extracted from spermatozoa, revealed five SHBG(TAAAA)n alleles with 6-10 repeats and 18 AR(CAG)n alleles with 12-32 repeats. The SHBG allelic distribution showed that in men with normal sperm count and motility, those with short SHBG alleles had higher sperm concentration than men with long SHBG alleles (P = 0.039). As concerns AR(CAG)n polymorphisms, men with short AR alleles had lower sperm motility compared to those with long AR alleles (P < 0.001) in both total study population and normal sperm count men. The synergistic effect analysis of the two polymorphisms revealed an association between sperm motility (P = 0.036), because of the effect of AR(CAG)n polymorphism on sperm motility. In conclusion, long AR alleles were found to be associated with higher sperm motility, while short SHBG alleles were associated with higher sperm concentration, supporting the significance of these genes in spermatogenesis and semen quality.

Effects of phosphodiesterase-5 inhibitors on sperm parameters and fertilizing capacity.

The aim of this review study is to elucidate the effects that phosphodiesterase 5 (PDE5) inhibitors exert on spermatozoa motility, capacitation process and on their ability to fertilize the oocyte. Second messenger systems such as the cAMP/adenylate cyclase (AC) system and the cGMP/guanylate cyclase (GC) system appear to regulate sperm functions. Increased levels of intracytosolic cAMP result in an enhancement of sperm motility and viability. The stimulation of GC by low doses of nitric oxide (NO) leads to an improvement or maintenance of sperm motility, whereas higher concentrations have an adverse effect on sperm parameters. Several in vivo and in vitro studies have been carried out in order to examine whether PDE5 inhibitors affect positively or negatively sperm parameters and sperm fertilizing capacity. The results of these studies are controversial. Some of these studies demonstrate no significant effects of PDE5 inhibitors on the motility, viability, and morphology of spermatozoa collected from men that have been treated with PDE5 inhibitors. On the other hand, several studies demonstrate a positive effect of PDE5 inhibitors on sperm motility both in vivo and in vitro. In vitro studies of sildenafil citrate demonstrate a stimulatory effect on sperm motility with an increase in intracellular cAMP suggesting an inhibitory action of sildenafil citrate on a PDE isoform other than the PDE5. On the other hand, tadalafil's actions appear to be associated with the inhibitory effect of this compound on PDE11. In vivo studies in men treated with vardenafil in a daily basis demonstrated a significantly larger total number of spermatozoa per ejaculate, quantitative sperm motility, and qualitative sperm motility; it has been suggested that vardenafil administration enhances the secretory function of the prostate and subsequently increases the qualitative and quantitative motility of spermatozoa. The effect that PDE5 inhibitors exert on sperm parameters may lead to the improvement of the outcome of assisted reproductive technology (ART) programs. In the future PDE5 inhibitors might serve as adjunct therapeutical agents for the alleviation of male infertility.

Selecting distending medium for out-patient hysteroscopy. Does it really matter?

BACKGROUND: The aim of this prospective randomized study was to evaluate the role of carbon dioxide (CO2) and normal saline for diagnostic accuracy in out-patient hysteroscopy. METHODS: Women admitted to our Department in order to undergo total abdominal hysterectomy also underwent diagnostic hysteroscopy, 12-24 h prior to surgery. The selection of distending medium was made after randomization. Two groups of patients were formed, group A (CO2; n=39) and group B (normal saline; n=35). More than half of the women in the study population were post-menopausal. Post-hysteroscopy, all women were asked to rank any symptom that they felt during the procedure on a 4-point scale (0=none; 1=mild; 2=severe; 3=inability to perform hysteroscopy). The hysteroscopic diagnosis was compared with the macroscopic findings and the histological examination of the surgical specimen after hysterectomy. RESULTS: The percentage who completed hysteroscopy was 89.74% within group A and 97.14% within group B. Most patients of both groups felt some pain of mild intensity. The diagnostic accuracy of hysteroscopy was similar for both media when major pathology [large polyps (group A 91.7%; group B 92.7%), myomas (group A 81.25%; group B 92.7%) and/or hyperplasia (group A 87.5%; group B 90.2%)] of the endometrial cavity was detected. In contrast, in cases of minor pathology (small polyps, mucosal elevations, crypts, hypervascularization), hysteroscopy with saline presented with significantly higher diagnostic accuracy (85.4%) compared with hysteroscopy with CO2 (64.6%). CONCLUSIONS: In out-patient hysteroscopy, CO2 and normal saline were comparable with regard to patient discomfort and for the detection of major pathology of the endometrial cavity. Normal saline seems to be the most appropriate medium for the detection of minor pathology of the endometrial cavity.

Should we advise patients undergoing IVF to start a cycle leading to a day 3 or a day 5 transfer?

BACKGROUND: The aim of this study was to compare ongoing pregnancy rates per started cycle between patients randomized at consultation to have embryo transfer either on day 3 or on day 5 of in-vitro culture. METHODS: All patients <43 years of age for whom IVF was indicated were allowed to participate in the study (day 3 group, 234 patients; day 5 group, 226 patients). Ovarian stimulation was performed either using GnRH antagonists/recombinant FSH (rFSH) (day 3, 70.1% of patients; day 5, 72.6% of patients) or using the long GnRH agonist protocol/urinary gonadotropins (day 3, 29.9% of patients; day 5 27.4% of patients). RESULTS: The random decision to initiate a cycle leading to day 5 as compared with a day 3 transfer was associated with a significantly lower chance of embryo cryopreservation (day 3, 61.5%; day 5, 50.4%; P<0.02). Ongoing pregnancy rate per started cycle did not differ between the two groups compared [day 3, 32.1%, 95% confidence interval (CI) 26.4-38.2%; day 5, 33.2%, 95% CI 27.3-39.5%]. CONCLUSIONS: Advising patients at consultation to initiate an IVF cycle leading to a day 5 as compared with a day 3 transfer does not appear to increase the probability of ongoing pregnancy, and is associated with a significantly lower probability of obtaining cryopreserved embryos.

Profound LH suppression after GnRH antagonist administration is associated with a significantly higher ongoing pregnancy rate in IVF.

BACKGROUND: The significance of suppressed LH levels in GnRH antagonist cycles for IVF outcome is currently unknown. The purpose of this study was to evaluate prospectively the association between LH levels and ongoing pregnancy achievement after GnRH antagonist initiation in IVF cycles. METHODS: Ovarian stimulation with a fixed dose of 200 IU recombinant FSH and daily GnRH antagonist (ganirelix) 0.25 mg from day 6 of stimulation was initiated in 116 women. Patients were not pretreated with an oral contraceptive. Induction of final oocyte maturation was performed with HCG 10,000 IU as soon as three follicles of > or =17 mm were present in ultrasound, and was followed by oocyte pick-up, conventional IVF or ICSI, and embryo transfer. The luteal phase was supplemented with vaginal progesterone. RESULTS: A significant decrease of both ongoing pregnancy rate and implantation rate was present across groups of patients with increasing LH levels. The highest implantation rate and ongoing pregnancy rate was present in those patients with LH levels on day 8 of stimulation < or =0.5 IU/l. CONCLUSIONS: Profound suppression of LH on day 8 of stimulation is associated with a significantly higher chance of achieving an ongoing pregnancy. More studies are necessary to evaluate this phenomenon further.

Elevated progesterone at initiation of stimulation is associated with a lower ongoing pregnancy rate after IVF using GnRH antagonists.

BACKGROUND: The objective of this prospective study was to assess the impact of elevated serum progesterone levels on day 2 of the cycle on pregnancy rates in patients treated by IVF using GnRH antagonists. METHODS: Ovarian stimulation was started on day 2 of the cycle if progesterone levels were normal (normal-P group, n = 390). In the presence of elevated progesterone, initiation of stimulation was postponed for 1 or 2 days (high-P group, n = 20) and was started if repeat progesterone levels returned to normal range (n = 16). Stimulation was performed with recombinant FSH (rFSH) and GnRH antagonist was always started on day 6 of stimulation. RESULTS: A significantly higher exposure to progesterone and a significantly lower exposure to estradiol was present in the high-P as compared with the normal-P group from day 1 to day 8 of stimulation. In addition, a significantly lower ongoing pregnancy rate both per started cycle (5.0% versus 31.8%; P = 0.01) and per embryo transfer (6.3% versus 36.9%; P = 0.01) was present in the high-P compared with the normal-P group, respectively. CONCLUSIONS: The presence of elevated serum progesterone on day 2 of the cycle is associated with a decreased chance of pregnancy in patients treated with rFSH and GnRH antagonists.

Endometrial thickness cannot predict ongoing pregnancy achievement in cycles stimulated with clomiphene citrate for intrauterine insemination.

To date, limited data exist concerning the relation between endometrial thickness on the day of human chorionic gonadotrohin (HCG) administration and ongoing pregnancy achievement in cycles stimulated with clomiphene citrate for intrauterine insemination (IUI). In a prospective study, 168 couples were stimulated with clomiphene citrate from day 3 to day 7 of the cycle and endometrial thickness was assessed by ultrasound three times on the day of ovulation triggering. Ovulation was induced with HCG as soon as >/=1 follicle of >/=17 mm was present at ultrasound independently of endometrial thickness. IUI was performed 36 h after HCG administration. The main outcome measure was ongoing pregnancy. No difference was observed in endometrial thickness between patients who did or did not achieve an ongoing pregnancy (7.6 +/- 0.3 versus 7.6 +/- 0.2 respectively; P = 0.7). No discriminative ability of endometrial thickness on the achievement of ongoing pregnancy could be shown by receiver operating characteristic (ROC) curve analysis (area under the ROC curve 0.51, 95% CI: 0.44-0.59). In conclusion, endometrial thickness cannot predict ongoing pregnancy achievement in IUI cycles stimulated with clomiphene citrate.

Factors affecting outcome after incomplete excision of cervical intraepithelial neoplasia.

PURPOSE: Conservative treatment for cervical intraepithelial neoplasia (CIN) by ablative or excisional techniques is widely used. However, women with incomplete excision have a variable risk of CIN recurrence. The aim of this study was to identify possible risk factors for recurrence of CIN after large loop excision of the transformation zone (LLETZ) with involved margins of excision. METHODS: All cases of women treated with LLETZ for CIN between 1989-2000, in whom histological evaluation of the excised specimen revealed extension of CIN to the excision margins, were retrospectively studied. A woman was considered to have recurrence when she had histologically confirmed CIN following a second LLETZ or hysterectomy during the follow-up period. The characteristics that were examined as possible risk factors were age, parity, smoking habit, grade of initial lesion and extension to the endo- or ectocervical margin. RESULTS: Treatment failure was diagnosed in 18 out of 65 (27.7%) women with involved margins. The only characteristic that reached statistical significance was age. The mean age of women with recurrence was 35.8 years, whereas the mean age of women without recurrence was 32.8 years (p = 0.044). Also, a trend was evident in women with high-grade initial lesions (CIN II-III) (p = 0.168) and involvement of the endocervical margins (p = 0.149). No differences were observed between the two groups regarding parity and smoking habit. CONCLUSIONS: Increased age is a risk factor for recurrence in women with incomplete excision of CIN after LLETZ. Larger studies are required for definite conclusions.

Implantation potential and clinical impact of cryopreservation--a review.

The ability of human embryos to survive the freezing and thawing process is reflected in their implantation potential. Although cryopreservation appears to affect adversely the capacity of human embryos to implant, it has also been shown to enhance consistently IVF outcome. Moreover, despite the reduced implantation potential of cryopreserved embryos as compared to fresh embryos, multiple pregnancies are frequent in frozen embryo transfer (FRET) cycles. There is no conclusive evidence that the stage of development at the time of freezing provides a clear advantage for the outcome of a FRET cycle. On the other hand, a decreased chance for pregnancy achievement appears to exist with advanced maternal age. Neither the mode of endometrium preparation nor the length of cryostorage appears to affect the outcome of FRET cycles which is positively associated to the achievement of pregnancy in the corresponding fresh cycle. Available evidence suggests that there are no adverse consequences in the babies born after embryo cryopreservation, although larger studies are necessary to allow solid conclusions.

Successful myomectomy during pregnancy.

BACKGROUND: Although leiomyomas usually remain asymptomatic during pregnancy, they may complicate its course. In this study, pregnancy outcome observed when myomectomy was performed during pregnancy in carefully selected patients is presented. METHODS: A prospective cohort study of 13 women who underwent myomectomy during pregnancy between January 1994 and December 2001. Surgical management of leiomyoma was required on the basis of characteristics of the myoma and symptoms. RESULTS: Among a total of 15,579 women registered at the authors' prenatal clinic, 622 consecutive pregnant women had sonographically identified myoma; hence, the incidence was 3.9% (95% CI 3.6-4.3%). The vast majority of these women was asymptomatic during pregnancy or managed conservatively (97.4%; 95% CI 96-98%). Among 622 pregnant patients with leiomyoma, 13 presented with complications during pregnancy that required surgical intervention (2.1%; 95% CI 0.9-3.2%), due to increase in lesion size causing discomfort and/or severe abdominal pain not responding to conservative management with analgesic and non-steroidal anti-inflammatory drug medication. In 92% of these cases, successful myomectomy was performed and the pregnancy progressed to term without further complications. CONCLUSIONS: These data provide reassurance for pregnant women with uterine myoma. Surgical management of uterine leiomyoma during pregnancy may be successfully performed in carefully selected patients.

Early pregnancy termination with vaginal misoprostol before and after 42 days gestation.

BACKGROUND: Misoprostol is a prostaglandin E(1) analogue that has been used for medical abortion. We conducted this prospective study to compare the efficacy of vaginal misoprostol for abortion in women at a gestational age of <42 days and in women at a gestational age of 42-56 days. METHODS: A total of 160 women seeking medical termination of a pregnancy of <56 days were enrolled in the study. Medical termination was performed using 800 micro g of vaginal misoprostol, repeated every 24 h for a maximum of three doses. RESULTS: The overall complete abortion rate was 91.3%. In group A (gestation <42 days) complete abortion occurred in 96.3% of women, whereas in group B (gestation = 42-56 days) complete abortion occurred in 86.3% of women (P < 0.025). The two groups did not differ significantly with respect to side-effects (incidence of pain, bleeding, nausea, diarrhoea, fever and headache). Women who had aborted successfully were significantly more satisfied with the method compared with women who did not (P < 0.001). CONCLUSIONS: The vaginal misoprostol-alone regimen is highly effective for women seeking medical abortion of pregnancies of

An observational study of women with positive HPV-DNA tests and normal cytology and colposcopy.

PURPOSE: High risk human papillomaviruses (HPV) are implicated in the aetiology of malignant cervical disease. The usefulness of HPV DNA tests in identifying women at risk of cervical cancer as an adjunct to cervical cytology is under evaluation. PATIENTS AND METHODS: This is a retrospective analysis of 47 women positive for high risk HPV but with negative cytology and negative colposcopy at the start of the study. Women were observed for three years or more (in 96% cases) using six-monthly combined HPV DNA tests, cytological and colposcopic evaluation. RESULTS: At the end of follow-up, 29/47 (62%) women were still positive for high risk HPV, 45/47 (96%) women had normal cytology and 47/47 (100%) women continued to have normal colposcopy. CONCLUSIONS: Normal colposcopy has an excellent negative predictive value for HPV positive women with normal cytology. These women can be safely screened cytologically on a three-yearly basis.