A. Zanatta

Extensive Excision of Deep Infiltrative Endometriosis before In Vitro Fertilization Significantly Improves Pregnancy Rates

STUDY OBJECTIVE We sought to compare the outcomes of in vitro fertilization (IVF) treatments in women with infertility-associated deep infiltrative endometriosis (DIE) who underwent extensive laparoscopic excision of endometriosis before IVF with those who underwent IVF only. DESIGN Prospective cohort study. SETTING Infertility clinic and private hospital in São Paulo, Brazil. PATIENTS A total of 179 infertile patients younger than 38 years had symptoms and/or signs of endometriosis and sonographic images suggestive of DIE. INTERVENTIONS After thorough counseling, 179 women were invited to participate in a prospective cohort study with 2 treatment options: IVF without undergoing laparoscopic surgery (group A, n = 105) and extensive laparoscopic excision of DIE before IVF (group B, n = 64). Ten women were lost to follow-up. The IVF outcomes were compared between the 2 groups. MEASUREMENTS AND MAIN RESULTS In group B, patients had 5 +/- 2 (mean +/- SD) DIE lesions excised during laparoscopy. Patient characteristics in groups A and B, respectively, were: age (32 +/- 3 vs 32 +/- 3 years, p = .94), infertility duration (29 +/- 20 vs 27 +/- 17 months, p = .45), day-3 serum follicle-stimulating hormone levels (5.6 +/- 2.5 vs 5.9 +/- 2.5 IU/L, p = .50), and previous IVF attempts (1 +/- 1 vs 2 +/- 1, p = .01). The IVF outcomes differed between groups A and B, respectively, with regard to total dose of recombinant follicle-stimulating hormone required to accomplish ovulation induction (2380 +/- 911 vs 2542 +/- 1012 IU, p = .01), number of oocytes retrieved (10 +/- 5 vs 9 +/- 5, p = .04), and pregnancy rates (24% vs 41%, p = .004), but not number of embryos transferred (3 +/- 1 vs 3 +/- 1, p = 1). The odds ratio of achieving a pregnancy were 2.45 times greater in group B than in group A. CONCLUSION Extensive laparoscopic excision of DIE significantly improved IVF pregnancy rates of women with infertility-associated DIE.

The role of the Hoxa10/HOXA10 gene in the etiology of endometriosis and its related infertility: a review

PurposeEndometriosis and its associated infertility have been the object of continuous research for over a century. To understand the molecular mechanisms underlying the disease, it has become necessary to determine the aspects of its etiology that are not explained by the retrograde menstruation theory. This could in turn elucidate how various clinical and surgical treatments might affect the evolution and remission of the disease.MethodsThis review is focused on the most recent clinical and laboratory findings regarding the association of HOXA10 with endometriosis and infertility.ResultThe homebox (Hox/HOX) proteins are highly conserved transcription factors that determine segmental body identities in multiple species, including humans. Hoxa10/HOXA10 is directly involved in the embryogenesis of the uterus and embryo implantation via regulation of downstream genes. Cyclical endometrial expression of Hoxa10/HOXA10, with a peak of expression occurring during the window of implantation, is observed in the adult in response to estrogen and progesterone. Women with endometriosis do not demonstrate the expected mid-luteal rise of HOXA10 expression, which might partially explain the infertility observed in many of these patients. Recent studies also demonstrated HOXA10 expression in endometriotic foci outside the Müllerian tract.ConclusionsMultiple lines of evidence suggest that the actions of the homeobox A10 (Hoxa10/HOXA10) gene could account for some aspects of endometriosis.

Should the Gynecologist Perform Laparoscopic Bowel Resection to Treat Endometriosis? Results Over 7 Years in 168 Patients

STUDY OBJECTIVE To assess the feasibility and safety of laparoscopic bowel resections for endometriosis performed by gynecologic surgeons. DESIGN Retrospective cohort study (Canadian Task Force Classification II-3). SETTING Fertility and pelvic surgery clinics. PATIENTS One hundred sixty-eight women (age 21-53 years) with symptoms including pelvic pain, infertility, or both with 252 bowel endometriotic lesions underwent laparoscopic bowel resection performed by gynecologic surgeons between May 2000 and January 2008. INTERVENTIONS Laparoscopic procedures for excision of several endometriotic nodes and lesions included shaving resection (LscShR), discoid resection (LscDR), segmental resection (LscSgR), terminal ileal resection (LscIR), partial cecal resection (LscCR), and appendectomy (LscAp). MEASUREMENTS AND MAIN RESULTS The 168 patients underwent 172 laparoscopic bowel resections (4 patients were operated on twice) by the same surgeon. Lesions were distributed as follows: 133 (79%) in the rectum, 61 (24%) in the sigmoid colon, 47 (19%) in the appendix, 5 (2%) in the terminal ileum, 3 (1%) in the descending colon, and 3 (1%) in the cecum. At surgeon discretion, 12 lesions were not resected. A total of 216 bowel procedures were necessary to remove the 240 lesions include shaving resection in 22 patients (10%), discoid resection in 52 (24%), segmental resection in 92 (42%), terminal ileal resection in 2 (1%), partial cecal resection in 1 (0.6), and appendectomy in 47 (22%). Major complications occurred in 13 patients (7.6%) and included rectovaginal fistula in 3 patients (1.7%), rectosigmoid anastomosis dehiscence and bowel occlusion in 1 patient each (0.6%), and persistent bowel dysfunction in 4 patients (2.3%). These results are comparable to those reported in the literature to date. Complete relief of symptoms (measured using the Visick scale) was noted in patients with dysmenorrhea (59%), dyspareunia (75%), noncyclic pelvic pain (90%), pain on defecation (100%), constipation (83%), and cyclic rectal bleeding (100%). CONCLUSION Surgery to treat bowel endometriosis can be safely and efficiently performed by the gynecologic pelvic surgeon. Meticulous training and a multidisciplinary approach to comprehensive operative care are necessary. These findings can be validated by prospective collaborative studies and reports from other surgeons.

Transvaginal US after bowel preparation for deeply infiltrating endometriosis: protocol, imaging appearances, and laparoscopic correlation.

Deeply infiltrating endometriosis (DIE) is a common gynecologic disease that is characterized by a difficult and delayed diagnosis. Radiologic mapping of the DIE lesion sites is crucial for case management, patient counseling, and surgical planning. Transvaginal ultrasonography (US) is the initial imaging modality for investigating DIE and has been the focus of several recent studies. DIE typically manifests at imaging as hypoechogenic nodules throughout the affected sites and thickening of the intestinal wall, with some lesions showing a mixed pattern due to cystic areas. Transvaginal US performed after bowel preparation improves the ability to diagnose intestinal lesions and provides invaluable details, including which layers of the intestine are affected and the distance between the lesion and the anal border. It is vital that radiologists be familiar with the technical aspects of this modality and with the US manifestations of DIE lesions. Transvaginal US performed after bowel preparation should be the first-line imaging modality for the evaluation of women with suspected endometriosis.

The feasibility of laparoscopic bowel resection performed by a gynaecologist to treat endometriosis

Purpose of review Intestinal endometriosis is commonly diagnosed in the setting of deeply infiltrating endometriosis. A multidisciplinary team that includes gynaecologists and general surgeons traditionally performs laparoscopic bowel resections for symptomatic patients. Recently, Pereira et al. has published the results of a series of patients who underwent laparoscopic bowel resection for endometriosis performed by a team of gynaecologic surgeons, after a period of experimental training with animals and joining participation with general surgeons in the first cases. It is suggested that gynaecologic surgeons may be able to perform laparoscopic bowel resections for endometriosis, if properly trained, although the results may not be reproducible. Recent findings A review of recent literature related to laparoscopic bowel resections for endometriosis showed that the learning curve and experience of the surgeon may be the most important predictive factors for the effectiveness of the procedure. Results concerning major operative complications and clinical remission were considered satisfactory in both single and multidisciplinary approaches, that is, laparoscopic bowel resections performed by gynaecologic and colorectal surgeons. Protective colostomies or ileostomies could not reduce the rate of rectovaginal fistulae in multidisciplinary experiences. Summary The single-surgeon model approach in laparoscopic excision of endometriosis that includes bowel resection may provide advantages for both the patients and healthcare system. The best model should be decided on the maximum benefit of the patient.

Transvaginal ultrasound after bowel preparation to assist surgical planning for bowel endometriosis resection

up 3 as those more than The rectosigmoid colon (RSC) is involved in up to 93% of all endometriotic lesions of the bowel [1]. Preoperative diagnosis of bowel endometriosis is very important for surgical planning and patient counseling. In this context, estimation of the distance from endometriotic lesions to the anal border hasmajor surgical implications because the risk of complications is greater for gastrointestinal anastomosis performed below the peritoneal reflection, in the lower rectum (less than 5 cm from the anal border) [2]. From the authors’ personal experience (MOCG and LPC), transvaginal ultrasound after bowel preparation (TVS-BP) improves the detection and characterization of intestinal lesions, permitting identification of the affected layers and the distance between the lower margin of the lesions and the anal border. Fifty-one patients who presented with endometriosis-associated infertility at the Huntington Medicina Reprodutiva Sao Paulo, Brazil, from October 2005 to October 2006 underwent TVS-BP measurement of the distance between RSC lesions to the anal border, and laparoscopic excision of endometriosis. Eighteen bowel lesions were resected in 16 women. During surgery, the actual distances between the endometriotic lesions and the anal border were recorded as the distance from the insertion of an endoscopic stapler at the anal border up to where the tip of the stapler touched the lesion. Lesions were divided into 3 groups based on their distance from the anal border, with group 1 categorized as those from1–5 cm (1/18; 5.6%); group 2 as those 6–10 cm (9/18; 50%); and gro

Successful Interval Laparoscopic Transabdominal Cervicoisthmic Cerclage Preceding Twin Gestation: A Case Report

Laparoscopic transabdominal cervicoisthmic cerclage (LTCC) is an alternative, less-morbid option to the traditional transabdominal cerclage, indicated for patients with cervical incompetence. Experience with the technique is based on case reports and a few case series. Considering LTCC for twin gestations, reports are very scarce and are derived from LTCC performed during pregnancy. We report the case of a 36-year-old patient, gravida 1, para 0, aborta 1, who underwent interval LTCC after a previous failed transvaginal emergency cerclage performed in the second trimester. Hysteroscopic metroplasty was concomitantly performed for an incomplete septate uterus. The procedure lasted 100 minutes, with an estimated blood loss of 50 mL. The patient was discharged home on the second postoperative day. The patient became pregnant with twins 3 months after the procedure after undergoing in vitro fertilization. The gestational course was uneventful, and the patient delivered 2 healthy neonates at 38 weeks gestation by elective cesarean section. The cerclage tape was left in situ. Minor modifications of the previously reported techniques included use of a laparoscopic Deschamps needle for placing the cotton cardiac tape used as suture material. Vessels in the cervical transverse cervical ligament were exposed before cerclage tape application. To our knowledge, this is the first report of interval LTCC preceding a twin gestation.

Laparoscopic dissection and anatomy of sacral nerve roots and pelvic splanchnic nerves.

STUDY OBJECTIVE To demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves. DESIGN Case report (Canadian Task Force classification III). SETTING Private practice hospital in São Paulo, Brazil. PATIENT A 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0-10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm. INTERVENTIONS Standard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4. MEASUREMENTS AND MAIN RESULTS The surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0-10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves. CONCLUSION Laparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.

Lactation Induction in a Commissioned Mother by Surrogacy: Effects on Prolactin Levels, Milk Secretion and Mother Satisfaction

Case report of a 39-year-old intended mother of a surrogate pregnancy who underwent induction of lactation by sequential exposure to galactagogue drugs (metoclopramide and domperidone), nipple mechanical stimulation with an electric pump, and suction by the newborn. The study aimed to analyze the effect of each step of the protocol on serum prolactin levels, milk secretion and mother satisfaction, in the set of surrogacy. Serum prolactin levels and milk production had no significant changes. Nevertheless, the mother was able to breastfeed for four weeks, and expressed great satisfaction with the experience. As a conclusion, within the context of a surrogate pregnancy, breastfeeding seems to bring emotional benefits not necessarily related to an increase in milk production.

Treatment of First Trimester Tubal Ectopic Pregnancy Through Posterior Colpotomy: Residents Can Easily Do It

Design: Women with uterine descent (stage 2 or more) who had been managed by laparoscopic sacrocolpopexy (LSCP) were invited to have pelvic d-MRI on their postoperative 6th month follow-up. P-QoL and FSFI forms were also filled by each woman. Setting: Tertiary care; university affiliated teaching hospital. Patients: Thirty women who had LSCP with polypropylene mesh were enrolled for the study. Intervention:MR imagingwas performed at rest and during straining in the supine position with slightly flexed legs using a 3TMR scanner. Midsagittal images at rest and on maximal strain were used for evaluation. M line, Pubococcygeal line (PCL), and mid-pubic line (MPL) were used to detect and grade prolapse.