Comparison of cervical vacuum cup cannula with metal cannula for hysterosalpingography.

OBJECTIVE: The aim of this study was to compare the use of a cervical vacuum cap cannula with the traditional metal cannula. DESIGN: A prospective, randomised, single-blinded comparative study. SAMPLE: Fifty consecutive infertile women undergoing hysterosalpingography for evaluation of infertility METHODS: Hysterosalpingography was performed either with the traditional metal cannula (n = 25) or a cervical vacuum cap cannula (n = 25). MAIN OUTCOME MEASURES: Length of procedure, fluoroscopic time, amount of contrast medium, pain to the patient while applying the cannula and injecting the contrast medium, level of difficulty to the performer, the need to reapply the cannula, complications, and results of the hysterosalpingography. RESULTS: Using the cervical vacuum cap cannula, compared with the metal cannula, the duration of the procedure was significantly shorter (5.3 vs 9.3 minutes; P < 0.001), less fluoroscopic time was needed (0.9 vs 1.8 minutes; P < 0.001), a smaller amount of contrast medium was used (4.6 vs 15.7 mL; P < 0.001), the procedure caused less pain to the patient (3.2 vs 6.8, respectively; on a scale of 1-10; P < 0.001), and was easier for the physician to perform (1.4 vs 3.4; on a scale of 1-10; P < 0.001). No significant differences were encountered between the two groups in the need to reapply the cannula, in the rate of complications or in the results of the hysterosalpingography. CONCLUSIONS: The cervical cap cannula appears to be superior to the traditional metal cannula for performing hysterosalpingography.

The accuracy of serum interleukin-6 and tumour necrosis factor as markers for ovarian torsion.

BACKGROUND: The aim of this study was to investigate a possible role for interleukin-6 (IL-6) and tumour necrosis factor (TNF-alpha) as pre-operative markers for the diagnosis of ovarian torsion. METHODS: Twenty consecutive patients admitted to the gynaecological emergency room with suspected clinical diagnosis of ovarian torsion were prospectively assigned to the study. Blood samples were drawn pre-operatively and examined for serum concentrations of IL-6 and TNF-alpha. Surgeons were blinded to laboratory results prior to laparoscopy. RESULTS: The pre-operative diagnosis of ovarian torsion was confirmed during an urgent diagnostic laparoscopy in 8 (40%) patients. The surgical diagnosis among the remaining 12 patients was a large ovarian cyst not in torsion. In six out of eight (75.0%) patients with ovarian torsion serum IL-6 concentrations were elevated. None of the 12 patients without torsion had elevated serum IL-6 concentrations. This difference was statistically significant (P < 0.001). There was no significant difference in the proportion of women with elevated serum TNF-alpha concentrations, two of eight (25.0%) patients with torsion and four of 12 (33.3%) control cases. CONCLUSIONS: Elevated serum IL-6 concentrations, but not serum TNF-alpha concentrations, were significantly associated with the occurrence of ovarian torsion. In patients with vague clinical signs of ovarian torsion, serum IL-6 might help to distinguish which patients should undergo diagnostic laparoscopy.

Hysteroscopy may be the method of choice for management of residual trophoblastic tissue.

STUDY OBJECTIVE: To assess the efficacy of and reproductive outcome after selective curettage of residual trophoblastic tissue directed by hysteroscopy compared with conventional, nonselective, blind curettage. DESIGN: Retrospective analysis (Canadian Task Force classification II-1). SETTING: Tertiary care medical center. PATIENTS: Seventy patients after curettage or delivery, with clinical and ultrasonographic signs of suspected residual trophoblastic tissue. MEASUREMENTS AND MAIN RESULTS: Twenty-four women underwent traditional curettage and 46 underwent hysteroscopic selective curettage. Five (20.8%) patients who underwent traditional curettage later required operative hysteroscopy due to persistent residual tissue. None of those who underwent hysteroscopic selective curettage needed a second operation. No patient in either group experienced anesthetic complications, perforation of the uterus, fluid overload, or other surgical complication. Reproductive outcome was similar in both groups, with tendency to conceive earlier in the hysteroscopy group, but no difference in overall pregnancy rates. CONCLUSION: Operative hysteroscopy for selective curettage of residual trophoblastic tissue should be considered an alternative to nonselective, blind curettage.

Accuracy of the preoperative diagnosis in 100 emergency laparoscopies performed due to acute abdomen in nonpregnant women.

STUDY OBJECTIVE: To assess the validity of preoperative diagnosis in the emergency room in relation to the surgical diagnosis at laparoscopy. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: One hundred consecutive nonpregnant women who underwent emergency laparoscopy for acute abdomen between 1997 and 1999. Intervention. Emergency diagnostic laparoscopy. MEASUREMENTS AND MAIN RESULTS: The preoperative diagnosis was confirmed by laparoscopy in 29 (44%) of 66 cases of ovarian torsion, 9 (82%) of 11 cases of ovarian cyst, and 12 (80%) of 15 cases of bleeding corpus luteum. Unsuspected diagnoses among nonconfirmed cases were ovarian cysts (24), adhesions (5), bleeding corpus luteum (3), degenerative myomas (3), pelvic inflammatory disease (2), and appendicitis (1). The preoperative diagnosis was confirmed by emergency laparoscopy in 56% of all patients. Diagnoses most likely to be predicted accurately were ovarian cysts and bleeding corpora lutea. Ovarian torsion was most difficult to diagnose preoperatively, as it was not confirmed during laparoscopy in over half patients. Ovarian cysts and adhesions were the most common unsuspected findings. CONCLUSION: Patients and surgeons alike should be aware of difficulty making accurate preoperative diagnoses of acute gynecologic pathologies in the emergency room. (J Am Assoc Gynecol Laparosc 8(1):92-94, 2001)

Management of women with polycystic ovary syndrome who experienced premature luteinization during clomiphene citrate treatment.

OBJECTIVE: To determine the preferred treatment modality in patients with PCOS who experienced premature luteinization during CC treatment. DESIGN: Prospective randomized study. SETTING: Tertiary medical center. PATIENTS: Twenty-two infertile women with PCOS demonstrating premature luteinization during at least two consecutive CC cycles. INTERVENTIONS: Randomized induction of ovulation either with FSH alone or with GnRH agonist combined with FSH for a single treatment cycle. MAIN OUTCOME MEASURES: Premature luteinization was defined as serum progesterone >1.5 ng/mL before hCG administration. RESULTS: Premature luteinization occurred in eight of the 10 patients (80%) in group A and in two of the 12 patients in group B (16.6%). This result corresponds to the higher mean (+/-SD) progesterone level present in group A patients as compared to those in group B (2.0 +/- 1.2 ng/mL vs. 1.2 +/- 0.6 ng/mL, P=0.03). No pregnancies were achieved in group A, whereas the pregnancy rate per cycle observed in group B was 33.3% (4/12). On the day of hCG administration, the maximum mean (+/-SD) estradiol level was significantly lower (P<0.0001) in group A (210.6 +/- 37.9 pg/mL) than in group B (600.3 +/- 253.8 pg/mL). The treatment duration and the number of FSH ampules used did not differ between the groups. CONCLUSIONS: Pituitary desensitization with GnRH analog in combination with FSH is superior to FSH-only treatment in PCOS patients who demonstrate premature luteinization during CC treatment.

Anti-cardiolipin antibodies in fetal blood and amniotic fluid derived from patients with the anti-phospholipid syndrome.

The aim of this study was to investigate whether, in patients with antiphospholipid syndrome, anticardiolipin antibodies pass from mother to offspring sera and amniotic fluid. Eleven patients with antiphospholipid syndrome (study group) and 11 healthy controls, matched by maternal and gestational age (control group) were prospectively examined for the presence of anticardiolipin antibodies in the cord blood during labour, and amniotic fluid during vaginal or Caesarean delivery. Three neonates (27.3%) in the study group had anticardiolipin antibodies in the cord blood, while none had them in the control group. Anticardiolipin antibodies were detected in the amniotic fluid in six (54.5%) of the study group pregnancies, compared with none in the control group. No adverse neonatal outcome was noted except for significantly lower (P < 0.0006) mean birth weight in the study group. Anticardiolipin antibodies can pass the placenta and be detected in fetal cord blood and amniotic fluid. This finding might be used in the future for the assessment of pregnancies with antiphospholipid syndrome.

Preferred treatment of infertile women older than 37 years of age who demonstrate premature luteinization in the first evaluation cycle.

OBJECTIVE: To evaluate the efficacy of various treatments in abolishing premature luteinization in infertile women over 37 years old who are undergoing ovulation induction. DESIGN: Prospective, nonrandomized study. SETTING: Tertiary care medical clinic. PATIENT(S): Seventeen infertile women >37 years old in whom premature luteinization was detected during their evaluation (pretreatment) cycle. INTERVENTION(S): The patients underwent three consecutive treatment cycles with clomiphene citrate (group A), hMG (group B), and a GnRH agonist plus hMG (group C). MAIN OUTCOME MEASURE(S): Premature luteinization, defined as a progesterone/E2 ratio of >1 on the day of hCG administration. RESULT(S): Fifteen (88%) of the 17 patients in group A and 13 (76%) of the 17 patients in group B demonstrated premature luteinization. In contrast, only 1 (6%) of the 17 patients in group C had a progesterone/E2 ratio of >1 on the day of hCG administration. The mean (+/-SD) E2 level on the day of hCG administration was significantly higher in group C (1.236 +/- 772.7 pg/mL) than in group A (214.02 +/- 104.46 pg/mL) or group B (412.5 +/- 337 pg/mL). CONCLUSION(S): Pituitary desensitization with a GnRH agonist in conjunction with hMG may be of benefit for older infertile women who demonstrate early luteinization in their first evaluation cycle.

The role of severe adnexal disease in tubal reconstructive surgery.

Fifty two consecutive women underwent microsurgical reconstruction of the tubes. Thirty one percent conceived and 19% delivered live infants. Medical history suggestive of pelvic infection was obtained in 44% of the women. Fifty four percent had extensive, coarse and fibrous adhesions. Tubal reconstruction in these patients did not yield any pregnancies. Severity of the adnexal disease should be evaluated before attempted tubal reconstructive surgery. Women with severe adnexal damage should be referred to in vitro fertilization.

PIP: The results of reconstructive tubal surgery performed without any preselection of patients were evaluated. 31% of the 52 consecutive women who underwent microsurgical reconstruction of the tubes conceived, and 19% delivered live infants. 4 women (8%) had spontaneous abortions -- 3 in the 1st trimester and 1 in the 2nd trimester. 2 (4%) women had ruptured tubal pregnancies and underwent salpingectomy. 20 patients (38%) had an unknown cause of tubal and peritoneal lesion. 10 (50%) conceived with 9 live birth infants and 1 spontaneous abortion. Reconstructive tubal surgery in patients with a known pelvic inflammatory disease and postpartum endometritis resulted in 3 (20%) pregnancies -- 2 spontaneous abortions and 1 tubal pregnancy. 44 (85%) women with peritubal and/or periovarian adhesions were analyzed according to the severity of their disease. 8 patients had tubal occlusion without peritoneal adhesions. 32 (62%) had grade III and IV adhesions. 3 patients with grade III adhesions conceived and none in grade IV. 2 tubal pregnancies occurred after lysis of adhesions and fimbrioplasty. Neosalpingostomy yielded 5 (22%) pregnancies and 3 (13%) live born infants. Repeated hysterosalpingograms were performed in 31 (60%) patients. In 15 (50%) the tubes were found to be reoccluded. 21 repeated diagnostic laparoscopies were performed. Of those women 10 had patent tubes and 3 of them conceived in 1 year. 11 patients had occluded tubes with grade III and IV adhesions. Repeated microsurgical reconstruction of the tubes was attempted in 2 patients, without any pregnancies in the follow up period of time. Severity of adnexal disease should be evaluated prior to attempted tubal reconstructive surgery. Women with severe adnexal damage should be referred to in vitro fertilization.