Saline contrast sonohysterography and directed extraction, resection and biopsy of intrauterine pathology using a Uterine Explora Curette.

OBJECTIVE: To assess the utility of an endometrial sampling device, the Uterine Explora Curette, with concomitant saline contrast sonohysterography (SCSH) for ultrasound-directed extraction, resection and biopsy of endometrial pathology. METHODS: Use of the Uterine Explora Curette was prospectively evaluated in 20 women with either infertility (n = 14), recurrent miscarriage (n = 2) or peri-/postmenopausal bleeding (n = 4). Findings on SCSH were compared with those on pathological analysis. RESULTS: In all 20 cases the Uterine Explora Curette was used successfully during SCSH to treat endometrial filling defects. The procedure was well tolerated, with an average time from start to finish of 10 (range, 2-23) min. It was without complications, and appeared to remove or biopsy adequately endometrial filling defects in most patients, obviating the need for hysteroscopy. CONCLUSIONS: In properly selected patients, directed extraction, resection and biopsy using the Uterine Explora Curette during SCSH appears to be an effective and easy method for treating intrauterine pathology and provides a cost-effective alternative to operative hysteroscopy.

Luteal phase support in infertility treatment: a meta-analysis of the randomized trials.

BACKGROUND: The addition of GnRH agonist to the treatment regimen in women undergoing IVF cycles is thought to create a luteal phase defect. In an attempt to correct for this, many practitioners supplement with a variety of steroid hormones in the luteal phase. METHODS: To determine whether luteal phase support increases reproductive success in modern IVF cycles, a systematic review of the literature was performed. Meta-analyses were conducted when multiple homogeneous studies addressed a single issue. Only randomized controlled trials were included in the data analysis. The efficacy of supplementation, as well as the optimal route, formulation, dose, and length of administration were queried. RESULTS: Luteal supplementation with either i.m. hCG or i.m. progesterone significantly improved fertility outcomes compared with no treatment. When comparing i.m. progesterone with i.m. hCG, no fertility differences were found. Intramuscular progesterone conferred the most benefit compared with oral or vaginal use. Addition of oral estrogen to progesterone also improved implantation rates. CONCLUSION: Given the increased risk of ovarian hyperstimulation syndrome associated with hCG use, i.m. progesterone is favoured for luteal phase supplementation with the addition of estrogen.

Fibroids and infertility: a systematic review of the evidence.

UNLABELLED: A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13--0.70) and implantation rates (RR 0.28; 95% CI 0.10--0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13--2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45--2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to summarize the data on the role of fibroids and infertility, describe the effect of myomectomy on fertility, and list the methods used to evaluate intracavitary fibroids.

Anesthesia for office endoscopy.

A trend is emerging in the United States whereby surgical procedures are gradually migrating to less complex environments. The demands of cost containment, pressures to limit unnecessary time delays, and desires for increased control have all conspired to promote ambulatory surgicenters, minor procedure center, and office surgical suites. Concomitant with this shift is a differing attitude toward anesthesia, with an increasing number of procedures using alternatives to general anesthesia, such as regional blocks and conscious sedation.

Evidence-based medicine: evaluating diagnostic tests.

Physicians have at their disposal a great number of established diagnostic tests, and new ones continue to be developed that are potentially helpful in diagnosing and establishing the prognosis of disease. Many of these tests were either inadequately evaluated or were found, on more careful scrutiny, to be less helpful than first believed. To ensure optimal patient care as well as appropriate use of health care resources, practitioners must be adept in understanding the true efficacy of diagnostic tests that they ask patients to undergo. They must be able to understand the basic language applied in evaluating tests and be able to determine if and when tests are applicable. (J Am Assoc Gynecol Laparosc 6(1):105-112, 1999)

Evidence-based medicine: study design for evaluation of treatment.

Obstetrician-gynecologists frequently rely on results of published studies to guide decisions regarding clinical management of their patients; that is, to practice evidence-based medicine. Therefore, it is essential that these studies be carried out meticulously. One of the first tasks in performing research is to select an appropriate study design. The principal designs are survey, which is a descriptive method; observational, which generates hypotheses; and experimental, which tests hypotheses, and is commonly called a randomized, clinical trial. Each one has advantages and limitations that must be considered carefully to achieve the most applicable effective results.

What is evidence-based medicine?

This is the first in a series of articles on evidence-based medicine. This series is intended to act as a primer for the novice who needs to understand more about the applications of this exciting new concept to the field of gynecology. The first article provides an overview of the field; future installments will discuss specific applications and techniques with regard to evidence-based medicine, and the assets and liabilities of putting this method into practice. It is hoped that the reader will find the material both practical and provocative.

Multifetal reduction of triplets to twins improves perinatal outcome.

OBJECTIVE: Our purpose was to compare the perinatal outcome of triplet pregnancies reduced to twins with the outcomes of continuing triplet pregnancies and twin pregnancies. STUDY DESIGN: Pregnancy outcomes of triplet pregnancies reduced to twins delivered between July 1988 and July 1992 were compared with pregnancy outcomes of continuing triplet and twin pregnancies delivered over the same time period. RESULTS: The mean gestational age at delivery for the reduced triplets was 35.6 weeks, compared with 31.2 weeks in the nonreduced triplets (p = 0.002). The perinatal mortality rate was 30 per 1000 births in the reduction group and 210 per 1000 births in the nonreduced triplets (p < 0.0001). There were no statistically significant differences between the reduced and nonreduced twins. CONCLUSION: Multifetal pregnancy reduction of triplets to twins yields an improved perinatal outcome compared with nonreduced triplets and a similar outcome compared with nonreduced twins.