FEMALE
INFERTILITY: Diagnosis
and treatment
Fertil
Steril 2002 Jan;77(1):83-90
Prediction of the individual follicle-stimulating
hormone threshold for gonadotropin induction of ovulation
in normogonadotropic anovulatory infertility: an approach
to increase safety and efficiency. Imani B, Eijkemans
MJ, Faessen GH, Bouchard P, Giudice LC, Fauser BC.
Division of Reproductive Medicine, Department of Obstetrics
and Gynecology, Erasmus University Medical Center
Rotterdam, Rotterdam, The Netherlands.
OBJECTIVE: To predict the FSH response (threshold)
dose in normogonadotropic, anovulatory infertile women
undergoing gonadotropin induction of ovulation. DESIGN:
Prospective longitudinal clinical study. SETTING:
Specialist academic fertility unit. PATIENT(S): Normogonadotropic,
oligoamenorrheic, infertile women who were resistant
to clomiphene citrate or in whom clomiphene citrate
therapy had failed. INTERVENTION(S): Daily exogenous
FSH administration in a low-dose, step-up regimen.
MAIN OUTCOME MEASURE(S): The FSH dose on the day of
ovarian response (follicle growth > 10 mm in diameter).
RESULT(S): Multivariate analysis was used to devise
the following equation to predict the individual FSH
response dose (75 to >187 IU/d) before initiation
of therapy: [4 body mass index (in kg/m(2))] + [32
clomiphene citrate resistance (yes = 1 or no = 0)]
+ [7 initial free insulin-like growth factor-I (in
ng/mL)] + [6 initial serum FSH level (in IU/L)] -
51. The SE of the predicted dose is 35 IU. CONCLUSION(S):
The individual FSH response dose for gonadotropin
induction of ovulation in anovulatory infertile women
can be predicted on the basis of initial screening
characteristics. The prediction model developed in
this study may increase the safety and efficiency
of low-dose gonadotropin protocols (step-up and step-down)
by correctly determining the appropriate starting
dose for a given patient.
Acta
Obstet Gynecol Scand 2002 Sep;81(9):882-5
Transvaginal hydrolaparoscopy: a new diagnostic
tool in infertility investigation. Jonsdottir K,
Lundorff P.
Department of Obstetrics and Gynecology, Viborg
sygehus, Heibergs Alle 4, 8800 Viborg, Denmark.
BACKGROUND: To establish the value of a new
technique called transvaginal hydrolaparoscopy for
exploration of the tubo-ovarian structures in the
management of patients with unexplained infertility.
METHODS: A total of 120 women with primary or secondary
infertility, and without obvious pelvic pathology,
were included in the study. The first 14 patients
received general anesthesia and underwent transvaginal
laparoscopy immediately before standard laparoscopy.
The remaining 106 patients had transvaginal laparoscopy
performed under local anesthesia, with standard
laparoscopy performed only on those with pathology,
which required operative intervention. Information
on pathology, complications, and successful access
to the pouch of Douglas were recorded. RESULTS:
The successful rate of access was 93%. Pathology
was found in 29 patients, of whom 15 required operative
laparoscopy. Also, out of 19 patients with adhesions,
11 (58%) had normal dye test bilateral, and only
two (11%) had bilateral occlusion of the tubes.
No complications were observed. CONCLUSION: Transvaginal
hydrolaparoscopy is a safe and well-tolerated method
for investigating the tubo-ovarian structures in
unexplained infertility. It is superior to hysterosalpingography
for diagnosis of adhesions.
Curr
Opin Obstet Gynecol 2002 Aug;14(4):397-400
One-stop endoscopy-based infertility clinic.
Brosens I, Campo R, Puttemans P, Gordts S.
Leuven Institute for Fertility and Embryology,
Leuven, Belgium. ivo.brosens@med.kuleuven.ac.be PURPOSE
OF REVIEW: The investigation of the infertile couple
is currently a highly debated issue. The purpose is
to review whether transvaginal hydrolaparoscopy in
combination with mini-hysteroscopy and chromopertubation
can be offered as a one-stop infertility investigation.
RECENT FINDINGS: The technique is based on the direct
visualization of the reproductive organs and the presence
of tubal patency, and has been clinically validated
during the past year for its accuracy, safety and
patient tolerance. SUMMARY: Further prospective randomized
studies are required to prove the superiority of transvaginal
hydrolaparoscopy in comparison with hysterosalpingography
as a first-line investigation in predicting the fertility
outcome.
Curr
Opin Obstet Gynecol 2002 Aug;14(4):381-5
Office hysteroscopy: a valuable but under-utilized
technique. Isaacson K.
Minimally Invasive Gynecological Surgery Unit,
Newton Wellesley Hospital, Newton, Massachusetts
02462, USA. kisaacson@partners.org
PURPOSE OF REVIEW: The purpose of this review is
to remind gynecologists of the indications for office
hysteroscopy as well as to provide an update on
equipment, techniques, and reimbursements. RECENT
FINDINGS: Office hysteroscopy is a technique that
has been available for over three decades. Whereas
nearly 100% of urologists utilize office cystoscopy
to evaluate bladder pathology, it is estimated that
less than 20% of gynecologists utilize office hysteroscopy
to evaluate intrauterine pathology. Although no
one knows for sure, I speculate that the reasons
for its under-utilization include a perceived lack
of patients who would benefit from the procedure,
expensive capital equipment with poor reimbursement,
and a lack of expertise in performing the procedure.
SUMMARY: As a result of not routinely using office
hysteroscopy, many women who could greatly benefit
from the use of the office hysteroscope are being
denied a technique that is likely to keep them from
more invasive and less useful procedures, such as
diagnostic hysteroscopy and dilatation and curettage
performed in the operating room under general anesthesia.
This paper addresses these misconceptions in an
effort to encourage more gynecologists to employ
this technology.
Ann
Epidemiol 2002 Jul;12(5):346-52
Desquamative inflammatory vaginitis: an exploratory
case-control study. Newbern EC, Foxman B, Leaman D,
Sobel JD.
Department of Epidemiology, University of Michigan
School of Public Health, Ann Arbor, MI 48109-2029,
USA.
PURPOSE: To investigate potential risk factors for
desquamative inflammatory vaginitis (DIV), a rare
but severe form of vaginitis. We are aware of no other
controlled studies of DIV. METHODS: We conducted a
case control study comparing DIV cases (n = 47), identified
from the Wayne State University Vaginitis Clinic,
to friend controls. For some variables, cases were
also compared to 1432 women participating in a random
digit dialing survey. RESULTS: Most cases reported
that their last episode of DIV caused at least some
pain (76.9%) and worry (73.1%). Cases were more likely
than either friend or population controls to report
(ORs from population controls) a history of vulvovaginal
candidiasis (OR = 4.40, 95% CI 2.24, 8.65), bacterial
vaginosis (OR = 25.58, 95% CI 15.91, 41.15), or pelvic
inflammatory disease (OR = 16.90, 95% CI 8.26, 34.55);
use of oral contraceptives (OR = 4.91, 95% CI 2.11,
11.43); use of hormone replacement therapy (OR = 4.74,
95% CI 2.69, 8.37); and laparoscopic procedures (OR
= 22.24, 95% CI 11.46, 42.69). CONCLUSIONS: Future
studies should be conducted to explain the association
with fertility surgeries, hormone usage, and other
urogenital conditions; to clarify the timing of these
associations; and to identify other factors related
to DIV.
Gynecol
Endocrinol 2002 Apr;16(2):151-4
Clomiphene citrate does not adversely affect
endometrial leukemia inhibitory factor levels. Kuscu
NK, Koyuncu FM, Var A, Lacin S, Uyanik BS, Ceylan
E.
Department of Obstetrics and Gynecology, School
of Medicine, Celal Bayar University, Manisa, Turkey.
nkk@ixir.com
The aim of this study was to compare endometrial
leukemia inhibitory factor (LIF) levels in spontaneous
and clomiphene citrate (CC)-induced cycles of patients
with unexplained infertility. The patients were
followed in two consecutive cycles. Endometrial
samples were obtained 7 days after ultrasonographic
evidence that ovulation has occurred during the
spontaneous cycle, then the patients were induced
with CC from day 5 to day 9 during the subsequent
cycle with 50 mg/day, and ovulation monitoring and
endometrial biopsy were performed in the same manner.
The samples were obtained using a Pipelle biopsy
device without using local anesthesia, and kept
in formaldehyde solution until the day of measurement.
Then they were homogenized in phosphate buffered
distilled water, and LIF levels were detected in
the homogenized fluid by ELISA method. Endometrial
LIF levels were 470 +/- 52 and 501 +/- 45 pg/1 gram
wet tissue in spontaneous and CC-induced cycles
respectively, revealing no significant difference.
Ovulation induction with CC did not adversely affect
endometrial LIF levels.
Hum
Fertil (Camb) 2002 Feb;5(1):G19-24; discussion G24-7,
G41-8
Monitoring during gonadotrophin-releasing hormone
antagonist protocols. Fleming R.
University Department of Obstetrics and Gynaecology,
Level 3 QEB, Royal Infirmary, Glasgow G31 2ER, UK.
The results of the four large industry sponsored
multicentre clinical trials comparing gonadotrophin-releasing
hormone (GnRH) antagonists and agonists in controlled
cycles of assisted reproduction are reviewed from
the perspective of implications for monitoring ovarian
responses. The simplicity and consistency of antagonist-controlled
cycles in normal women indicate that patients in assisted
reproduction programmes should undergo fewer assessments
and will receive shorter treatment cycles. However,
the two-stage pattern of follicular recruitment in
antagonist-controlled cycles leads to follicles of
different size profiles at the end of the follicular
phase compared with those obtained in agonist-controlled
cycles (one recruitment process only). Increasing
the dose of follicle-stimulating hormone (FSH) may
increase oocyte yield, but does not obviate the difference
between the two types of cycle. This difference has
implications for the criteria used to determine timing
of administration of the luteinization signal before
oocyte retrieval.
Hum
Reprod 2002 Mar;17(3):525-7
Chlamydia trachomatis in subfertile women undergoing
uterine instrumentation. Screen or treat? Land JA,
Gijsen AP, Evers JL, Bruggeman CA.
Research Institute Growth and Development (GROW),
Department of Obstetrics and Gynaecology, P.O. Box
5800, 6202 AZ Maastricht, The Netherlands. jlan@sgyn.azm.nl
Women who undergo uterine instrumentation are considered
at risk for pelvic infections by Chlamydia trachomatis,
which may derive either from ascending endocervical
infections or from reactivation of micro-organisms
persisting in the genital tract after previous chlamydia
infections. Women presenting at fertility clinics
frequently undergo uterine instrumentation (e.g.
hysterosalpingography and laparoscopy with hydrotubation).
Studies in subfertile women using DNA amplification
techniques have shown that the prevalence of endocervical
chlamydia infections is low (1.8%). In contrast,
in 30-60% of subfertile women chlamydia IgG antibodies
can be found in serum, indicating previous chlamydia
infections. It has been demonstrated that, several
years after chlamydia infections, viable micro-organisms
may still be present in the upper genital tract.
Therefore, subfertile women with chlamydia antibodies
should be considered at risk for reactivation of
persistent chlamydia infections after uterine instrumentation,
even after exclusion of endocervical chlamydia infections.
Moreover, in subfertile women without chlamydia
antibodies, the presence of viable micro-organisms
in the genital tract cannot be excluded. As a consequence,
prophylactic antibiotics before uterine instrumentation
should be considered in all subfertile women, instead
of endocervical screening for C. trachomatis and
treatment of positive cases only.
Ultrasound
Obstet Gynecol 2001 Nov;18(5):525-30
Assessment of Fallopian tube patency by HyCoSy:
comparison of a positive contrast agent with saline
solution. Boudghene FP, Bazot M, Robert Y, Perrot
N, Rocourt N, Antoine JM, Morris H, Leroy JL, Uzan
S, Bigot JM.
Department of Radiology, Hopital Tenon, Universite
Paris 6, France. frank.boudghene@tnn.ap-hop-paris.fr
OBJECTIVE: To compare the efficiency of air-filled
albumin microspheres (Infoson) with saline solution
in determining Fallopian tube patency during hysterosalpingo
contrast sonography (HyCoSy). METHODS: This was a
prospective randomized multicenter study with a sequential
design. Over a 10-month period, 23 patients (mean
age, 33 years) referred for infertility were examined
by HyCoSy (saline or Infoson) before conventional
hysterosalpingography (Iopamiron 370), performed during
the same session. Contrast agents were administered
through a 5-F Ackrad balloon catheter inserted transcervically
into the uterine cavity. HyCoSy was performed with
a 7-MHz transvaginal probe using both B-mode and color
Doppler, and tubal patency was demonstrated by the
appearance of contrast agent in the peritoneal cavity
near the ovaries. Data were registered for each patient
during the examination and the results were monitored
by sequential analysis. RESULTS: Mean volumes of contrast
injections were 35.3 mL of saline, 14.4 mL of Infoson,
and 13.8 mL of Iopamiron 370. Infoson-enhanced HyCoSy
provided a significantly larger (P = 0.006) number
of correct diagnoses (20/22 Fallopian tubes) than
did saline HyCoSy (12/24 Fallopian tubes), and the
same number as that achieved by hysterosalpingography.
CONCLUSION: A positive ultrasound contrast agent appears
to be more efficient than saline solution at determining
Fallopian tube patency in infertile women by means
of HyCoSy, and as efficient as an iodinated contrast
agent in the same population explored by HSG. HyCoSy
could be used to screen infertile women, thereby avoiding
the use of iodinated contrast medium and exposure
to ionizing radiation during conventional HSG in patients
with patent Fallopian tubes.
Gynecol
Endocrinol 2001 Dec;15(6):421-5
Ovulation induction with pulsatile gonadotropin-releasing
hormone (GnRH) or gonadotropins in a case of hypothalamic
amenorrhea and diabetes insipidus. Georgopoulos
NA, Markou KB, Pappas AP, Protonatariou A, Vagenakis
GA, Sykiotis GP, Dimopoulos PA, Tzingounis VA.
Department of Obstetrics and Gynecology, Division
of Reproductive Endocrinology, University of Patras
Medical School, Rio-2650, Greece.
Hypothalamic amenorrhea is a treatable cause of
infertility. Our patient was presented with secondary
amenorrhea and diabetes insipidus. Cortisol and
prolactin responded normally to a combined insulin
tolerance test (ITT) and thyrotropin-releasing hormone
(TRH) challenge, while thyroid-stimulating hormone
(TSH) response to TRH was diminished, and no response
of growth hormone to ITT was detected. Both luteinizing
hormone (LH) and follicle-stimulating hormone (FSH)
levels increased following gonadotropin-releasing
hormone (GnRH) challenge. No response of LH to clomiphene
citrate challenge was detected. Magnetic resonance
imaging findings demonstrated a midline mass occupying
the inferior hypothalamus, with posterior lobe not
visible and thickened pituitary stalk. Ovulation
induction was carried out first with combined human
menopausal gonadotropins (hMG/LH/FSH) (150 IU/day)
and afterwards with pulsatile GnRH (150 ng/kg/pulse).
Ovulation was achieved with both pulsatile GnRH
and combine gonadotropin therapy. Slightly better
results were achieved with the pulsatile GnRH treatment.
Contrib
Gynecol Obstet 2000;20:13-20
Hysteroscopy in infertility--diagnosis and treatment
including falloposcopy. Hucke J, De Bruyne F, Balan
P.
Department of Obstetrics and Gynaecology, Krankenhaus
Bethesda, Wuppertal, Germany.
Diagnostic hysteroscopy should be included routinely
in the work-up of invasive examinations for infertility
patients. Anyhow, one can rarely expect to find the
definite underlying reason for infertility. In infertile
patients about 20% of hysteroscopic examinations show
some grade of intrauterine abnormalities. Congenital
uterine malformations are the most frequently found
disorders. In the group of patients with habitual
abortions abnormalities are found much more often
and can also be more often interpreted as the mainly
underlying factor for the repeated abortions. Operative
hysteroscopy has become the surgical method of first
choice for the treatment of uterine septa, submucous
myomas, polyps and synechia. After septum dissection
results are excellent. Myoma removal also shows beneficial
effects on fertility; nevertheless, cases are not
too frequent among infertility patients. In cases
of high-grade Asherman's syndrome, the prognosis after
hysteroscopic surgery is still often poor.
Fertil
Steril 2002 Jan;77(1):173-5
A randomized controlled trial of tubal flushing
with lipiodol for unexplained infertility. Nugent
D, Watson AJ, Killick SR, Balen AH, Rutherford AJ.
Centre for Reproduction, Growth and Development,
University of Leeds, LGI, Belmont Grove, Leeds,
United Kingdom. dnhello@hotmail.com
OBJECTIVE: To test the hypothesis that, in couples
with unexplained infertility, tubal flushing with
an oil-soluble media (lipiodol) would increase the
pregnancy rate within 6 months compared with expectant
management. DESIGN: A prospective, randomized, controlled
study in which couples were allocated to either
a single treatment with lipiodol or no further action.
SETTING: Two tertiary referral centers for assisted
reproduction. PATIENT(S): Couples with a diagnosis
of primary or secondary unexplained infertility
based on a normal semen analysis according to World
Health Organization criteria, patent fallopian tubes
at hysterosalpingography or laparoscopy, and ovulatory
menstrual cycles based on midluteal phase progesterone
levels or ultrasonic follicle tracking. INTERVENTION(S):
In those patients randomized to lipiodol, a single
treatment was performed. MAIN OUTCOME MEASURE(S):
Biochemical (i.e., positive pregnancy test) and
clinical (i.e., fetal heart on ultrasound scan)
pregnancy rates. RESULT(S): Seventeen couples were
randomized to lipiodol and 17 to expectant treatment.
The higher pregnancy rate after lipiodol was statistically
significant. There were no complications after lipiodol
treatment. CONCLUSION(S): There was a statistically
significantly higher pregnancy rate in couples with
unexplained infertility randomized to a single tubal
flush with lipiodol compared with no treatment.
Hum
Reprod Update 2001 Nov-Dec;7(6):581-90
Ovarian reserve testing and the use of prognostic
models in patients with subfertility. Bukman A, Heineman
MJ.
Department of Obstetrics and Gynaecology, Section
of Reproductive Medicine, University Hospital Groningen,
The Netherlands. a.bukman@og.azg.nl
The decline in fecundity with female age is a well-known
phenomenon for clinicians dealing with subfertility
patients. Diminishing ovarian reserve seems to be
the reason for declining fecundity. Since age is only
a rough estimate of ovarian reserve, many tests have
been developed to predict ovarian reserve more precisely.
This review focuses on these ovarian reserve tests
and their clinical role in predicting response to
ovarian stimulation and pregnancy chances. According
to our analysis, the clomiphene citrate challenge
test has the strongest correlation in predicting ovarian
reserve, and is the only test that is validated in
the general infertility population. The antral follicle
count by ultrasound is promising and may offer clinical
use. It is not known whether a combination of tests
can provide more accurate information of ovarian reserve.
It is not yet clear to which extent the results of
ovarian reserve tests can be incorporated into the
available prognostic models. There is a need for prospective
cohort studies that focus on prognostic factors among
which are the results of ovarian reserve tests. Only
then can the qualitative and quantitative relevance
of ovarian reserve testing in the context of the prognosis
for couples with subfertility be established.
Hum
Reprod Update 2001 Nov-Dec;7(6):567-76
Clinical implications of postsurgical adhesions.
Diamond MP, Freeman ML.
Division of Reproductive Endocrinology and Infertility,
Wayne State University School of Medicine, Detroit,
MI 48201, USA. Adhesion development can have a major
impact on a patient's subsequent health. Adhesions
are a significant source of impaired organ functioning,
decreased fertility, bowel obstruction, difficult
re-operation, and possibly pain. Consequently, their
financial sequelae are also extraordinary, with
more than one billion dollars spent in the USA in
1994 on the bowel obstruction component alone. Performing
adhesiolysis for pain relief appears efficacious
in certain subsets of women. Unfortunately even
when lysed, adhesions have a great propensity to
reform. Adhesions are prevalent in all surgical
fields, and nearly any compartment of the body.
For treatment of infertility and recurrent pregnancy
loss, lysis of intrauterine adhesions results in
improved fecundability and decreased pregnancy loss.
Gynecol
Obstet Invest 2001;52(3):184-8
Results of a prospective comparative study of transvaginal
hydrolaparoscopy and chromolaparoscopy in the diagnostics
of infertility.
Nawroth F, Foth D, Schmidt T, Romer T.
Department of Obstetrics and Gynaecology, University
of Cologne, Germany. Frank.Nawroth@medizin.uni-koeln.de
Transvaginal hydrolaparoscopy (THL) was evaluated
in comparison with the already established chromolaparoscopy
in the detection of tubal factors, adhesions as well
as endometriosis. 43 infertile patients without previous
pelvic operations and with an inconspicuous clinical
examination were included in a prospective comparative
study of THL and chromolaparoscopy. THL succeeded
in 40 patients (93.0%). Both methods showed 100% agreement
with regard to tubal factors and adhesions. However,
only 72/80 tubes (90.0%) could be portrayed by THL.
In contrast to this, THL failed to identify 8 of 10
laparoscopically verified endometrioses (isolated
endometriosis of the bladder peritoneum in 2). No
complications occurred with THL. THL could be the
method of choice for the clarification of mechanical
infertility factors in symptom-free patients with
no suspicion of pelvic pathologies. Tubal pathologies
and/or adhesions (visible during THL) should be indications
for laparoscopy. In the case of inconspicuous genitals
during THL and a still unfulfilled desire for offspring
postoperatively, laparoscopy should be considered
in order to exclude the possibility of unidentified
endometriosis. Retroflexio uteri should at least be
a relative contraindication for THL. Further studies
are necessary to evaluate the role of THL in the diagnostic
concept of infertility in the future.
Ann
N Y Acad Sci 2001 Sep;943:269-75
Laparoscopic myomectomy fertility results. Dubuisson
JB, Chapron C, Fauconnier A, Babaki-Fard K.
Service de Chirurgie Gyneologique Clinique Universitaire
Baudelocque, Hjpital Cochin, Paris, France. jean-bernard.dubuisson@cch.ap-hop-paris.fr
The appearance of uterine myomas has been linked
to infertility. It has been suggested that surgical
management of myomas by laparoscopic myomectomy
improves fertility rates in these group of patients.
In this paper we initially describe specific aspects
of the surgical technique of laparoscopic myomectomy
including the set-up, precise technique for hysteroromy,
enucleation of the myoma, suturing of the uterus,
and extraction of the myoma. We detail recent findings
that demonstrate improved fertility rates in women
undergoing laparoscopic myomectomy. We recommend
that, when criteria for selection of patients is
strictly adhered to and patients present with no
other associated infertility, laparoscopic myomectomy
be used to increase the implantation rate.
Hum
Fertil (Camb) 2001;4(3):145-51
Clomiphene citrate in the twenty-first century.
Nasseri S, Ledger WL.
Division of Clinical Sciences, Section of Reproductive
and Developmental Medicine, The Jessop Wing, Tree
Root Walk, Sheffield S10 2SF, UK.
Clomiphene citrate is the drug most commonly prescribed
for ovulation induction. It is the first choice medication
in normogonadotrophic oligo/amenorrhoeic infertility
(WHO group 2), essentially associated with polycystic
ovaries. Anovulatory women who are responsive to clomiphene
citrate should be treated for at least six cycles
and the treatment should probably be limited to a
maximum of 12 cycles. It is necessary to monitor at
least the first cycle with ultrasonography because
of the risk of multiple pregnancy and the variable
response of patients to different doses of clomiphene.
In addition, the risk of ovarian hyperstimulation
syndrome should not be underestimated. More triplets
and higher order pregnancies result from ovulation
induction than from in vitro fertilization, and multiple
pregnancy has many risks for both mother and babies.
The role of empirical clomiphene in the treatment
of unexplained infertility is debatable and the present
data are inconclusive. Obesity, hyperandrogenaemia
and insulin resistance are important factors in clomiphene-resistant
patients. Failure to ovulate in response to clomiphene
has been approached by either medical or surgical
treatment. An effective alternative medical treatment
is gonadotrophin injections. Treatment with metformin
and the new generation of insulin-sensitizing drugs
is under evaluation. The most widely used surgical
treatment today is laparoscopic ovarian drilling,
which appears to be as effective as gonadotrophin
therapy.
J
Am Assoc Gynecol Laparosc 2001 Aug;8(3):393-7
Diagnostic and operative transvaginal hydrolaparoscopy
for infertility and pelvic pain. Moore ML, Cohen
M.
Advanced Women's Health Institute, University
of Colorado Health Sciences Center, 210 University
Boulevard, Suite 500, Denver, CO 80206, USA.
STUDY OBJECTIVE: To review our experience with diagnostic
and operative transvaginal hydrolaparoscopy (THL),
a procedure that is less invasive than operative
laparoscopy. DESIGN: Prospective, observational
cohort study (Canadian Task Force classification
II-2). SETTING: Private institute and university-affiliated
hospital. PATIENTS: Twenty-nine women with infertility
and 11 with pelvic pain. INTERVENTIONS: Diagnostic
and operative THL. MEASUREMENTS AND MAIN RESULTS:
Thirty-five (88%) diagnostic THLs were performed
in the office and the other five were done in hospital
for insurance reasons; all six operative THLs were
performed in the office under conscious sedation.
The procedure was conclusive (all organs seen) in
37 patients (93%). Based on THL, no further surgical
intervention was recommended in 18 (62%) infertile
women and 5 (45%) of those with pain. Further surgical
intervention was required in 5 (56%) of 9 infertility
patients with a previous normal hysterosalpingogram
(HSG) and 6 (32%) of 19 infertility patients with
no previous HSG. CONCLUSION: Transvaginal hydrolaparoscopy
can be performed in the office with minimal pain,
with a conclusive examination anticipated in 93%
of cases. The procedure is more accurate than HSG
and similar to laparoscopy.
1:
Obstet Gynecol Surv 2001 Aug;56(8):483-91
Fibroids and infertility: a systematic review of
the evidence. Pritts EA.
Department of Obstetrics and Gynecology, University
of California, San Francisco 94143-0056, USA. lapskyboy@aol.com
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.
Fertil
Steril 2001 Aug;76(2):370-4
Determinants of pregnancy rate and obstetric
outcome after laparoscopic myomectomy for infertility.
Dessolle L, Soriano D, Poncelet C, Benifla JL, Madelenat
P, Darai E.
Hopital Hotel-Dieu de Paris, Paris, France.
OBJECTIVE: To determine the effect of myomectomy
on infertility and to assess the factors influencing
reproductive outcome. DESIGN: Retrospective study.
SETTING: Tertiary care center. PATIENT(S): One hundred
and three infertile women with uterine leiomyoma
who had had infertility >2 years and a follow-up
time >12 months were enrolled. Follow-up was complete
for 88 patients, including 28 (31.8%) with primary
infertility and 44 (50%) with unexplained infertility.
The mean (+/-SD) age of the patients was 36.1 +/-
2.1 years. INTERVENTION(S): Laparoscopic myomectomy.
MAIN OUTCOME MEASURE(S): Pregnancy rate according
to patient and fibroid characteristics. RESULT(S):
Forty-two patients became pregnant (40.7%). The
mean (+/-SD) delay in conception was 7.5 +/- 2.6
months. Nearly 80% of the women conceived spontaneously.
Of 44 pregnancies in 42 women, 36 live newborns
were delivered. No dehiscence of uterine scar occurred.
The pregnancy rate was significantly higher in women
<35 years of age or <3 years of infertility. Women
with unexplained infertility had higher pregnancy
rate than did women with multifactorial infertility
(P<.001). No difference was noted in pregnancy rates
according to fibroid characteristics. CONCLUSION(S):
Fertility and pregnancy after laparoscopic myomectomy
depend primarily on patient age, duration of infertility
before myomectomy, and existence of associated infertility
factors.
Fertil
Steril 2001 Aug;76(2):342-5
Salpingographic demonstration of "cobblestone"
mucosa of the distal tubes is indicative of irreversible
mucosal damage.
Lang EK, Dunaway HE Jr.
Tulane University School of Medicine, New Orleans,
Louisiana, USA. OBJECTIVE: To establish the predictive
value of the observation of a "cobblestone" pattern
of the distal tube mucosa shown on the selective salpingogram
as an indicator of significant and probably irreparable
damage to the ciliated epithelium. DESIGN: Clinical
study. SETTING: Fertility and Laser Center and Academic
Radiology Department. PATIENT(S): Patients with primary
or secondary infertility and obstruction of the fallopian
tubes documented on hysterosalpingogram. INTERVENTION(S):
Transcervical recanalization of obstructed tubes followed
by reassessment by selective salpingogram. MAIN OUTCOME
MEASURE(S): Progression of mucosal disease with resultant
low likelihood of intrauterine pregnancies and high
probability of ectopic pregnancy. RESULT(S): In 32
asymptomatic patients, there was progression to coalescence
and agglutination of mucosal folds in 13, to a thick
wall pyosalpinx in 4. Five thin wall and 8 thick wall
hydrosalpinges in asymptomatic patients showed no
significant progression of mucosal disease but increasing
peritubular fibrosis. In 12 symptomatic patients,
progressive fusion of mucosal folds with polypoid
hyperplasia was observed in 11, a thin wall hydrosalpinx
in 2. CONCLUSION(S): Cobblestone appearance of the
distal tubes heralds significant mucosal damage, prone
to progressive disease and hence, a poor chance for
conception
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