Uterine cavity-myoma fistula after hysteroscopic myomectomy mimicking uterine perforation at hysterosalpingography: case report.

Fistula formation between the uterine cavity and the cavity of a subserosal myoma was diagnosed at laparoscopy/hysteroscopy in a 39-year-old woman with primary infertility. The patient had undergone 2 previous hysteroscopic resection procedures for removal of a submucosal myoma as part of infertility treatment. Hysterosalpingography demonstrated leakage of contrast medium from the uterine cavity, a characteristic feature of uterine perforation. At hysteroscopy/laparoscopy, a defect was observed in the posterior wall of the uterine cavity with connection to the cavity of a subserosal myoma without any tract to the peritoneal cavity. Laparoscopic myomectomy was performed to repair the uterine wall defect at the site of the fistula. Subsequently, the patient conceived after an office-based gonadotropin cycle therapy and is currently 20 weeks pregnant.

Is a placebo-controlled surgical trial an oxymoron?

Within the context of the new medical methodology of evidence-based medicine, the ethical issues of making the randomized, placebo-controlled, clinical trial part of the matrix of surgical procedure evaluation are discussed. Surgical trials with alternative research design less rigorous than the double-blind, placebo-controlled, randomized trial leave the alternative: implementing surgical procedures based on anecdotal evidence and weaker scientific research. The conundrum of these clinical trials, as it relates to the evaluation of surgical procedures, is that it appears to confound some of the fundamental ethical principles of beneficence and nonbeneficence. The placebo effect with surgery is so strong that "sham surgery" within the clinical trial context is essential and an appropriate component of the ethics of clinical research. A discussion of these issues is presented.

Abnormal uterine bleeding: imaging techniques for evaluation of the uterine cavity and endometrium before minimally invasive surgery--the case for transvaginal ultrasonography.

Transvaginal ultrasound has been utilized for first line evaluation of abnormal uterine bleeding since its development in the early 1980's. The benefits and diagnostic effectiveness of transvaginal ultrasound in assessing the uterus, unlike hysteroscopy, extends to the complete pelvis. The ease of application, patient acceptance, and immediacy of results are rapidly apparent. Comparisons with hysteroscopic evaluation are discussed. While tissue diagnosis is still the gold standard, transvaginal sonography lets one know what surgical procedure to plan for from hysteroscopy to Endoscopy or laparotomy, including when no further surgical evaluation is necessary.

GnRH analogs: options for endometriosis-associated pain treatment.

While none of the currently available treatment options for endometriosis pain resolved the underlying disease process, there are growing numbers of medical alternatives available. Medical options include the GnRH agonists and antagonists. Review of these treatments in the management of endometriosis pain and the insight often to the etiology of endometriosis are presented for discussion.

Postmortem parenthood and the need for a protocol with posthumous sperm procurement.

OBJECTIVE: Posthumous sperm procurement involves harvesting gametes from a recently deceased man for cryopreservation and future use in ART. This paper discusses the practical and ethical role of posthumous sperm procurement in medical practice and society and submits possible solutions, including the establishment of formal policies and protocols. DESIGN: English-language literature review and bioethical discussion. RESULT(S): In the United States, an increase in requests and protocols has been documented. International requests and regulation are variable. CONCLUSION(S): Posthumous sperm procurement is fraught with ethical dilemmas, including informed consent, privacy, inheritance, and child welfare. To establish appropriate medical practice, it is important to consider all stakeholders in the decision-making process. We believe that an acceptable and ethical resolution can be obtained only through the collaborative input of all involved parties. We have looked to U.S. and international sources for guidance in current practice and to gain insight into the formulation of future policies.