Ahmed Saleh

Reoperation after laparoscopic treatment of ovarian endometriomas by excision and by fenestration

OBJECTIVE To compare the reoperation rate after laparoscopic treatment of ovarian endometriomas by excision and by fenestration. DESIGN Retrospective study. SETTING University-affiliated teaching hospital. PATIENT(S) Two hundred thirty-one premenopausal women with ovarian endometriomas treated laparoscopically. INTERVENTION(S) Seventy women were treated with fenestration and ablation of the cyst wall and 161 women were treated with excision. MAIN OUTCOME MEASURE(S) The reoperation rates of the two groups of women were evaluated using life-table analysis. RESULT(S) The cumulative probability of reoperation was significantly higher after fenestration than after excision. The reoperation rates at 18 months and 42 months of follow-up were 6.1% and 23.6% after excision and 21.9% and 57.8% after fenestration, respectively. In the fenestration group, the age of the patient and the diameter of the endometrioma were not associated with a higher reoperation rate. In the excision group, a larger cyst was associated with a higher reoperation rate, but age had no influence on the reoperation rate. CONCLUSION(S) Laparoscopic excision of ovarian endometriomas is associated with a lower reoperation rate than that of fenestration. The reoperation rate after fenestration is independent of the size of the endometrioma and the age of the patient. However, after excision, the reoperation rate is higher in those with larger cysts.

Surgical management of ectopic pregnancy.

Laparoscopic salpingostomy remains the definitive and universal treatment of ectopic pregnancy in patients who are hemodynamically stable and who wish to preserve their fertility. The reproductive performance after salpingostomy appears to be equivalent or better than salpingectomy, but the recurrent ectopic pregnancy rate may be slightly greater. Expectant management has a poor efficacy and unproven benefit in subsequent reproductive outcome. Its use should be limited to situations in which the ectopic pregnancy is suspected but cannot be detected by transvaginal ultrasound. Methotrexate is an alternative to surgical treatment in selected patients who fulfill strict inclusion criteria, including compliance with follow-up evaluation. A large, prospective, randomized trial with significant power is needed, however, to study the prognostic factors for methotrexate success. The most practical and efficient method of methotrexate administration is a single intramuscular injection. Those who do not meet the criteria for methotrexate therapy should be treated surgically, which can be done by laparoscopy. Interstitial pregnancy also can be treated with methotrexate. Otherwise, a cornual resection or salpingotomy can be done. Although, it is feasible by laparoscopy, the laparoscopic approach should be done only by those who have an expertise in laparoscopic suturing. Abdominal and ovarian pregnancies are best treated surgically. Further, the diagnosis usually is established by laparoscopy, and an appropriate surgical treatment can be conducted at the same time.

Effects of laparoscopic ovarian drilling on serum vascular endothelial growth factor and on insulin responses to the oral glucose tolerance test in women with polycystic ovary syndrome.

OBJECTIVE To evaluate the serum vascular endothelial growth factor concentrations and insulin responses to the oral glucose tolerance test before and after laparoscopic ovarian drilling in women with PCOS. DESIGN Prospective study. SETTING University teaching center. PATIENT(S) Twenty-seven women with clomiphene citrate-resistant polycystic ovary syndrome. INTERVENTION(S) Laparoscopic ovarian drilling. MAIN OUTCOME MEASURE(S) VEGF levels and insulin responses to OGTT before and after ovarian drilling. RESULT(S) No difference was found in VEGF levels in women with PCOS before (6.0 +/- 1.2 ng/mL) and after ovarian drilling (5.5 +/- 1.2 ng/mL). VEGF levels before and after ovarian drilling in women who conceived were, respectively, 5.9 +/- 1.0 and 5.1 +/- 0.9 ng/mL and in those who did not conceive were 6.0 +/- 1.3 and 5.7 +/- 1.2 ng/mL. No correlation was found between baseline serum insulin and VEGF levels. VEGF concentrations in women with normal ovaries (4.5 +/- 1.7 ng/mL) were significantly lower than in women with PCOS. There was no difference in glucose and insulin responses to OGTT before and after ovarian drilling. CONCLUSION(S) VEGF levels in women with PCOS are higher than in normal women, and ovarian drilling does not affect these levels. The procedure does not change insulin responses to OGTT.

A randomized study of the effect of 10 minutes of bed rest after intrauterine insemination

OBJECTIVE To evaluate the effects of 10 minutes of bed rest after intrauterine insemination (IUI) on the pregnancy rate. DESIGN Prospective randomized study. SETTING University teaching hospital. PATIENT(S) One hundred sixteen couples with unexplained infertility. INTERVENTION(S) Patients were prospectively randomized either to immediate mobilization after IUI (group I) or to remain in a supine position for 10 minutes after the procedure (group II). MAIN OUTCOME MEASURE(S) Cumulative pregnancy rate. RESULT(S) Ninety-five couples were included in the analysis. Group I consisted of 40 couples (90 cycles), and group II consisted of 55 couples (120 cycles). The pregnancy rate per couple in group I (4 of 40 [10%]) was significantly lower than in group II (16 of 55 [29%]). The pregnancy rate per cycle in group I (4.4%) was also lower than in group II (13. 3%). With use of life-table analysis, the cumulative probability of pregnancy in group II was significantly higher than in group I. CONCLUSION(S) A 10-minute interval of bed rest after IUI has a positive effect on the pregnancy rate. We recommend that mandatory bed rest for 10 minutes after IUI should be adopted into a standard practice.

Effects of Local Bupivacaine Instillation on Pain after Laparoscopy

STUDY OBJECTIVE To evaluate the effect of preincisional and intraperitoneal bupivacaine administration on immediate and late pain after operative laparoscopy. DESIGN Randomized study (Canadian Task Force classification I). SETTING University teaching hospital. PATIENTS One hundred fifty women undergoing laparoscopy for various gynecologic indications. INTERVENTION A dose of 0.5% bupivacaine 10 ml (50 mg) was injected into cannula sites before incisions and another 10 ml diluted with 100 ml saline into the peritoneal cavity at completion of the procedure. Equal amount of physiologic saline was used in controls. MEASUREMENTS AND MAIN RESULTS Modified McGill pain intensity scores and amount of analgesic required in the recovery room and within 24 hours postoperatively were evaluated. Of 150 women, 142 completed the study (71 bupivacaine group, 71 controls). Groups did not differ significantly in body mass index, duration of surgery, return to consciousness, and analgesic requirement during 3-hour observation in the recovery room and 24 hours after discharge. Pain scores were highest 30 minutes after the procedure in both groups. At that time the pain score in the bupivacaine group was lower than that in the control group (1.8 +/- 0.2 vs 2.3 +/- 0.2, p <0.05). Beyond that time, the groups did not differ in pain scores and analgesic requirements. CONCLUSION Postoperative pain is the highest within 30 minutes after laparoscopy. Local instillation of bupivacaine before incision and intraperitoneally was effective in reducing pain immediately after operative laparoscopy, but the effect was not seen beyond 30 minutes.

Effects of laparoscopic ovarian drilling on adrenal steroids in polycystic ovary syndrome patients with and without hyperinsulinemia

OBJECTIVE To evaluate adrenal steroid responses to ACTH stimulation and insulin responses to oral glucose tolerance test (OGTT) in clomiphene-citrate-resistant anovulatory women with polycystic ovary syndrome (PCOS) before and after laparoscopic ovarian drilling. DESIGN Prospective study. SETTING Healthy participants in a university teaching hospital. PATIENT(S) Twenty clomiphene-citrate-resistant anovulatory women with PCOS. INTERVENTION(S) Laparoscopic ovarian drilling. MAIN OUTCOME MEASURE(S) Adrenal steroid responses to ACTH stimulation and insulin responses to OGTT before and after ovarian drilling. RESULT(S) Fourteen of 20 women completed the study. There was a correlation between body mass index and basal insulin levels before ovarian drilling. This correlation was lost after surgery. Area-under-the-curve glucose and insulin values before surgery in women with hyperinsulinemia (1,033.3 +/- 112.7 mmol/L and 141,919 +/- 26,177 pmol/L, respectively) were significantly higher than in those with normoinsulinemia (777.1 +/- 77.2 mmol/L and 69,867 +/- 19,390 pmol/L respectively, P<.05). There was a significant difference in insulin and glucose responses before and after ovarian drilling in women with hyperinsulinemia. No difference was found in women with normoinsulinemia. There was no significant difference in adrenal steroid responses to ACTH stimulation before and after ovarian drilling. CONCLUSION(S) PCOS women with hyperinsulinemia respond differently to laparoscopic ovarian drilling than do those with normoinsulinemia. Among women with hyperinsulinemia, surgery decreases glucose and insulin responses to OGTT. Regardless of the insulin level, laparoscopic ovarian drilling does not influence adrenal steroid dynamics.

Endometriosis: critical assessment of current therapies

Depending upon the symptomatology, treatment of endometriosis can be complex and difficult. In the absence of a definitive knowledge of the aetiology of the disease, treatment remains symptomatic. The medical management of endometriosis involves hormonal manipulation abolishing ovulation and causing secondary atrophy of the endometriotic implants. The efficacy of progestogens, danazol, or gonadotropin-releasing hormone (GnRH) agonists are somewhat similar and the choice of individual treatment should be determined by the age and symptoms of the patient as well as the side effects of the drug. As anovulation is the principal mode of action, the use of these treatments in women desirous of pregnancy is inappropriate. The role of anti-progestogens and immunomodulating agents remains to be determined. Surgical treatment is primarily by the laparoscopic route and the aim is to excise or ablate the endometriotic implants, as well as to remove endometriomata and divide adhesions. Conservative laparoscopic treatment should be the treatment of choice for patients presenting with infertility or endometriomas. Bilateral oophorectomy and hysterectomy will usually result in a complete cure, but should be reserved for those with severe endometriosis and obviously when no more children are desired.

Diagnosis of simple endometrial hyperplasia in a woman with polycystic ovary syndrome with use of hysterosalpingography

A 35-year-old woman presented with a 2-year history of secondary infertility. Her condition was diagnosed as polycystic ovary syndrome on the basis of clinical symptoms (oligomenorrhea and hirsutism), elevated serum androgen levels, and the characteristic appearance of ovaries by ultrasound as described elsewhere (1). A transvaginal ultrasound scan of the uterus demonstrated thickened endometrium (14 mm). A hysterosalpingogram revealed an endometrial cavity with multiple filling defects (Fig. 1). The fallopian tubes were patent. Diagnostic hysteroscopy revealed features of endometrial hyperplasia. Dilatation and curettage confirmed the presence of simple endometrial hyperplasia. The patient was treated with cyclic progestin for 10 days for three cycles, and an endometrial biopsy did not reveal any abnormalities. A repeat hysterosalpingogram showed normal findings.