Ali M. El Saman

Reproductive outcome after transplantation of ovarian tissue: a systematic review

BACKGROUND Despite interest in ovarian tissue transplantation (OTT) as a promising procedure for fertility preservation, to date, no precise data are available about its effectiveness. We systematically reviewed reproductive function after OTT for fertility preservation in women at high risk of premature ovarian failure (POF). METHODS We searched the MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science and Scopus databases for studies on the reproductive outcomes after OTT in humans up to June 2007. Women with follicle-stimulating hormone (FSH) >30 IU/l at the time of OTT were included in a meta-analysis of individual-patient data to evaluate the time to re-establishment of ovarian function (ROF). Secondary outcomes included short-term (<12 months) and long-term (>12 months) ovarian function (OVF) and pregnancy after OTT. RESULTS We identified 25 reports including 46 unique cases. OTT was performed to treat POF in 27 women, to prevent POF in 15, to treat infertility in 2 and accidentally in 1. In 23 women with FSH >30 at the time of OTT, OVF was re-established with a median time to ROF of 120 days (range 60-244). Within 6 months after ROF, four women had recurrent ovarian failure. There are insufficient data to evaluate the long-term OVF (>12 months). Fresh grafts had an increased likelihood of return of OVF and a decreased likelihood for recurrent ovarian failure compared with cryopreserved grafts [HR of 2.44 (95% CI 0.92, 6.49) and 0.47 (95% CI 0.18, 1.12), respectively]. In 25 women who sought pregnancy, eight women had nine pregnancies at 12 months, giving a cumulative pregnancy rate of 37% (95% CI 19, 60). CONCLUSIONS Transplantation of ovarian tissue can re-establish OVF after POF; however, the efficacy of OTT using cryopreserved tissues is not yet equivalent to that of fresh grafts. A controlled multicenter trial with sufficient follow-up would provide valid evidence of the potential benefit of this procedure.

Retropubic balloon vaginoplasty for management of Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE To study operative, postoperative, anatomic, and functional outcomes of retropubic balloon vaginoplasty (RBV) for the management of vaginal aplasia. DESIGN Case series with description of the technique. SETTING Assiut University Woman Heath Center. PATIENT(S) Three women with vaginal aplasia due to müllerian agenesis. All had pelvic adhesions due to previous surgeries. INTERVENTION(S) A Foley catheter was inserted in the retropubic space from the suprapubic area to the vaginal dimple. Cystoscopy was done to ensure bladder and urethral integrity. Patients were treated postoperatively by controlled traction and distension for a week. MAIN OUTCOME MEASURE(S) Depth and width of neovagina, penetration, and satisfaction scores. RESULT(S) The mean operative time was 9 to 11 minutes. No operative complications were recorded. Pain scores ranged from 0 to 20 points at rest and from 20 to 50 points during dressing. Vaginal depth as well as penetration and satisfaction scores showed statistically significant increases. CONCLUSION(S) Retropubic balloon vaginoplasty is a simple, safe, and effective alternative approach for creation of a neovagina, especially when laparoscopy is unfeasible or unsafe.

Endoscopically monitored canalization for treatment of congenital cervical atresia: the least invasive approach

OBJECTIVE To study feasibility, safety, and anatomic and functional outcomes of endoscopically monitored canalization for treatment of congenital cervical atresia. DESIGN Case series with description of the technique. SETTING Assiut University Womens Health Center. PATIENT(S) Five with congenital cervical atresia, two of them with associated vaginal aplasia. INTERVENTION(S) The three cases with isolated cervical atresia underwent laparoscopic canalization under vaginoscopic monitoring (LC-VM). The two cases with associated vaginal aplasia underwent laparoscopic canalization under tactile monitoring (LC-TM). Cystoscopy was done for all cases to ensure bladder and urethral integrity. MAIN OUTCOME MEASURE(S) Operative time, complication rate, menstrual pattern, and reintervention rate. RESULT(S) The LC-VM procedure was performed successfully in three cases within 20-25 minutes. The two cases with associated vaginal aplasia underwent LC-TM; one them was successful and the other was complicated with bladder puncture. Follow-up ranged from 3 to 36 months, and all had regular menstruation. CONCLUSION(S) Laparoscopic canalization under vaginoscopic monitoring is a simple, effective, and minimally invasive way of management of isolated cervical atresia. However it seems not to be the ideal technique and needs further refinements for treatment of cervical atresia associated with vaginal aplasia.

Distension versus traction in laparoscopically assisted balloon vaginoplasty for management of vaginal aplasia.

Creation of a neovagina in women with vaginal aplasia using laparoscopically assisted balloon vaginoplasty (LAB-V) has been described previously [1]. The creation of the neovagina depends on the traction and distension of the Foley catheter balloon. Alternative procedures such as sigmoid neovaginoplasty, McIndoe procedure, and peritoneoplasty are more technically demanding and have higher complication rates [1]. Preliminary results attest to the safety and effectiveness of LAB-V [1,2]. It is possible that traction contributes length to the neovagina, while distension contributes width. The most important contributing factor to satisfactory sexual intercourse is unknown. The aim of the present prospective study was to compare the effects of postoperative predominant traction and predominant distension on penetration and sexual satisfaction among women undergoing LAB-V and their partners. Eighteen women with vaginal aplasia were included in the study. Sexual satisfaction was measured using a visual analogue scale from zero to 100 and divided into 10 compartments, with 100 representing maximum satisfaction and 0 representing no satisfaction. Each womans partner was assessed using a similar scale to measure depth of penetration and sexual satisfaction. After counseling about the procedure and the alternatives, the patients were randomly allocated to either the predominant distension group (PD) or the predominant traction group (PT) after informed consent was obtained. Ethical approval was granted by the Department of Obstetrics and Gynecology. The operative procedure was the same for both groups [1] and was performed by one of the authors [AME]. Postoperative care consisted of preventing infection [1], and controlled traction and distension in each group but at different levels. In the PD group, the balloon was distended at 5 mL/day to a maximum of 40 mL reached on the seventh postoperative day. The catheter was then removed the following day. Tractionwas performed at a rate of 1 cm per day. In the PT group, traction was done daily using the catheter to the level of patient tolerance (maximum 3 cm) and controlled distension at a rate of 3 mL every other day. Counter traction was applied in both groups every 20–30 minutes during the

Enhancement balloon vaginoplasty for treatment of blind vagina due to androgen insensitivity syndrome

OBJECTIVE To evaluate the safety and feasibility of enhancement balloon vaginoplasty (EBV) in cases with blind vagina due to androgen insensitivity syndrome. DESIGN Case series with description of the technique. SETTING Womens Health Center, Assiut University, and Sohage Teaching Hospital, Sohage University. PATIENT(S) Three X,Y females (two cases presenting with apareunia and the third presenting with severe dyspareunia). INTERVENTION(S) Laparoscopy-assisted EBV. MAIN OUTCOME MEASURE(S) Operative time, complications, depth and width of neovagina, and functional status. RESULT(S) Our cases were currently married phenotypical females and had 46,X,Y karyotypes. They had well developed secondary sexual characters, but they presented with failure of intravaginal intercourse. EBV was performed successfully for three X,Y females. The total operative time was 38-45 minutes. No operative complications were reported, and there were no reported postoperative complications as a result of moving the direction of traction. The resultant neovaginas depths were 10, 11, and 12 cm, respectively. Sexual intercourse was set off on the day of discharge. Penetration and satisfaction scores increased up to 90 points for both partners. CONCLUSION(S) It was feasible and safe to move centrally the direction of traction and to move the point of catheter exit up with apparently better outcomes than conventional balloon vaginoplasty for treatment of blind vagina due to androgen insensitivity syndrome.

Combined retropubic balloon vaginoplasty and laparoscopic canalization : A novel blend of techniques provides a minimally invasive treatment for cervicovaginal aplasia

We studied the operative and functional outcomes of combined retropubic balloon vaginoplasty and laparoscopic canalization (RBV-LC) for treatment of cervicovaginal aplasia. The RBV-LC procedure was performed successfully in 4 cases of cervicovaginal aplasia within 35-40 minutes primary operative time. Cystoscopy was performed to ensure bladder and urethral integrity. Endoscopically monitored canalization with laparoscopic canalization is a feasible, effective, less invasive way for management of cervicovaginal aplasia.

Is there a role for hysteroscopic tubal occlusion of functionless hydrosalpinges prior to IVF/ICSI in modern practice?

Objectives. To determine whether hysteroscopic tubal occlusion will produce the same efficacy as laparoscopic tubal occlusion of functionless hydrosalpinx prior to IVF/ICSI. Design. A prospective comparative study. Setting. Endoscopy Unit of the Womens Health Center, Faculty of Medicine, Assiut University, Assiut, Egypt. Subjects. A pilot safety phase included 10 uteri removed by hysterectomy in perimenopausal women subjected to roller ball coagulation of the peritubal bulge. The study phase included 27 patients with uni‐ or bilateral functionless hydrosalpinges, who were randomly divided into 2 groups. Group A comprised 14 patients who were randomly allocated for laparoscopic occlusion. Group B included 13 patients scheduled for a hysteroscopic approach. Interventions. Laparoscopic occlusion of the isthmic part of the fallopian tube was carried out using bipolar diathermy in 9 (64%) cases or clips in 3 (21.4%) cases in Group A. Roller ball electrode of the resectoscope was utilised for occlusion of the tubal ostium under local, spinal, or general anesthesia in Group B. Second‐look office hysteroscopy was performed in Group B whenever possible. In both groups, hysterosalpingography or sonohysterography was carried out 1 month later to confirm tubal occlusion. Main outcome measures. Safety phase aimed at confirming tubal occlusion with minimal harm to adjacent tissues. Confirmed tubal occlusion of the functionless hydrosalpinx. Results. The safety phase resulted in bilateral complete occlusion of the proximal part of the tubes with secondary coagulation <8 mm, as shown in the histopathologic sections. The suspected main cause of functionless hydrosalpinges was iatrogenic (pelvic surgery) in 9 (64%) and 8 (61.5%) cases in both groups, respectively. The mean number of abdominal scars/patient was 1.4 and 1.5 in both groups, respectively. Unilateral functionless hydrosalpinx was encountered in 7 (50%) and 5 (38%) cases in both groups, respectively. In Group A, the procedure was possible and successful in 10 cases (76.9%), while in Group B, hysteroscopic access and occlusion were achieved in 12 (85.7%) and 9 (64.2%) cases, respectively. In Group B, diagnostic hysteroscopy showed fine marginal adhesions in 2 cases (15%), and a small polyp in 1 case (7.7%). Hysteroscopic tubal occlusion showed shorter operative time (9±2.8 versus 24±4.8min, p = 0.0001) and hospital stay (2±1.8 versus 5±1.1h, p = 0.0001). Second‐look office hysteroscopy was performed in 8 cases in Group B and revealed no significant corneal lesions at the site of hysteroscopic occlusion. Conclusions. This preliminary study demonstrates the feasibility of hysteroscopic tubal occlusion of functionless hydrosalpinx in all cases with acceptable efficacy. It has the advantage of adding a valuable evaluation of the endometrial cavity prior to IVF/ICSI. It should be an option for treatment protocol in cases of functionless hydrosalpinges. Further large sample‐sized studies are required to test its impact on the implantation rate and clinical outcome.

Modified balloon vaginoplasty: the fastest way to create a natural neovagina Minor changes in technique eliminate the need for customized instruments

We studied the feasibility of performing balloon vaginoplasty (BV) with conventional laparoscopic instruments through 2 modified techniques aiming at providing BV for open use. Three of 6 cases with vaginal aplasia were offered modified laparoscopically assisted balloon vaginoplasty (LAB-V) and the other 3 cases underwent modified retropubic balloon vaginoplasty (RBV). We measured operative time, complications, anatomical outcomes, functional outcomes, and re-intervention rates. Modified RBV and LAB-V were performed successfully in the 6 cases within 9-12 and 29-38 min, respectively. The neovagina depths were 8-10 and 9-12 cm, respectively. Anterior rectal wall needle puncture was encountered in 1 case of LAB-V group and posterior urethral wall puncture in an abnormally dilated urethra in 1 case of the RBV group; both cases passed uneventfully. Intercourse was initiated after removal of all catheters. The neovagina was a cosmetically appealing mimic to nature and stained with iodine up to its apex. It was feasible to perform balloon vaginoplasty operations without specialized instrument sets with comparable outcomes.

Müllerian duct anomalies: successful endoscopic management of a hybrid bicornuate/septate variety.

STUDY OBJECTIVE To highlight the coexistence of uterine septum in cases diagnosed as bicornuate uterus on basis of the external shape of uterine fundus. STUDY DESIGN Case report with description of the technique. SETTING Womens Health Assiut University Hospital. PARTICIPANTS An adolescent female with progressive pains dating since menarche. INTERVENTIONS Hysteroscopic resection under laparoscopic monitoring through an intact hymen. MAIN OUTCOME MEASURE Operative time, complications, postoperative abdominal pain, appearance of the uterine cavity RESULTS A patient with a septate uterus with a fundal depression and hemiuterine obstruction underwent hysteroscopic resection under laparoscopic monitoring. Laparoscopy was beneficial in diagnosis and treatment of associated pathology and monitoring the hysteroscopic procedure. Hysteroscopic metroplasty was performed and resulted in unification of the lower two thirds of the uterus. Dysmenorrhea was dramatically improved after the procedure. Subsequent office hysteroscopy confirmed restoration of a unified lower uterine corpus anatomy mimic to the original bicornuate state. CONCLUSIONS External fundal depression which characterizes bicornuate uterus was associated with a septate uterus with hemi uterine obstruction. This report demonstrates the coexistence of the two anomalies. Endoscopic management of this patient was safe and successful.

Hybrid septate uterus, coexistence of bicornuate and septate varieties: A genuine report

Aim:  To highlight the coexistence of a uterine septum in cases diagnosed as bicornuate uterus on the basis of the external shape of the uterine fundus and to present the outcomes of its hysteroscopic management.