Atef M. Darwish

Evaluation of the impact of laparoscopic ovarian drilling on Doppler indices of ovarian stromal blood flow, serum vascular endothelial growth factor, and insulin-like growth factor-1 in women with polycystic ovary syndrome

OBJECTIVE To study the serum levels and correlation of vascular endothelial growth factor (VEGF), insulin-like growth factor 1 (IGF-1), hormonal profile, and Doppler blood flow changes within the ovarian stroma before and after laparoscopic ovarian drilling (LOD) in women with clomiphene-resistant polycystic ovary syndrome (PCOS). DESIGN Prospective controlled study. SETTING University teaching hospital. PATIENT(S) Twenty-five women with clomiphene-resistant PCOS (group 1) and 20 women with regular menstrual cycles as a comparison group (group 2). INTERVENTION(S) Laparoscopic ovarian drilling. MAIN OUTCOME MEASURE(S) Serum levels of VEGF, IGF-1, and Doppler indices of ovarian stromal blood flow. RESULT(S) The serum levels of VEGF, IGF-1, T, and LH were significantly higher in group 1 before LOD than in group 2. The Doppler indices (pulsatility index and resistance index) of ovarian stromal blood flow were also significantly lower in group 1 before LOD than in group 2. The serum levels of VEGF, T, and LH were significantly reduced in group 1 after LOD compared with in group 1 before LOD. Doppler indices (pulsatility index and resistance index) of ovarian stromal blood flow were significantly increased after LOD. The VEGF levels before LOD were positively correlated with IGF-1, LH, and T. After LOD, the VEGF levels were positively correlated with LH and T. CONCLUSION(S) Higher serum levels of VEGF and IGF-1 may explain the increased vascularity that was demonstrated by Doppler blood flow measurements in PCOS. Laparoscopic ovarian drilling reduced serum VEGF, IGF-1, T, and LH and reduced ovarian blood flow velocities, which may explain the reduction of ovarian hyperstimulation syndrome in women with PCOS after LOD.

Comparison of transvaginal ultrasonography and vaginal sonohysterography in the detection of endometrial polyps

Background. The diagnostic accuracy of transvaginal ultrasonography and vaginal sonohysterography in detecting endometrial polyps in women suffering abnormal uterine bleeding are compared.

Screening sonohysterography in infertility.

This prospective comparative study was carried out to assess the value of sonohysterography (SHG) in evaluating both the endometrial cavity and tubal patency in infertile patients and to compare its results with hysterosalpingography (HSG), diagnostic hysteroscopy and laparoscopic chromopertubation. It comprised 84 infertile women who were examined using SHG the day before combined diagnostic laparoscopy and hysteroscopy. Eighty-three patients had had HSG within 6 months. As regards the appearance of the endometrial cavity, the results of SHG agreed with hysteroscopy in 72.2% (k = 0.31) while HSG agreed with hysteroscopy in 75.6% (k = 0.39) of cases. The appearance of the right and left tubes using SHG agreed with laparoscopy in 72.4% (k = 0.16) and 60.5% (k = 0.13), respectively, while HSG agreed with laparoscopy in 94% (k = 0.52) and 90.4% (k = 0.51), respectively. However, when the appearance of fluid in DP was considered as an indirect indicator of patency of at least one tube at SHG, the agreement with laparoscopy rised to 88.1% (k = 0.24) and 85.7% (k = 0.18) for both tubes respectively. In conclusion, SHG is similar to HSG as regards the appearance of the endometrial cavity but it is inferior to it for evaluating tubal factor. The implication of SHG in the infertility work-up as a simple and fast procedure can minimize costs and abuses of sophisticated techniques particularly in the developing countries with limited resources.

Biological effects of distension media in bipolar versus monopolar resectoscopic myomectomy: A randomized trial

Aim:  To estimate the effect of 0.9% saline during bipolar resectoscopy and 1.5% glycine during monopolar resectoscopy on hemodynamic, biochemical and hematological parameters.

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.

Treatment options for bacterial vaginosis in patients at high risk of preterm labor and premature rupture of membranes

Aim:  To estimate the efficacy of different therapeutic modalities on proven cases of bacterial vaginosis (BV) in patients at high risk of preterm labor and premature rupture of membranes.

Fine needle vaginoplasty: a simplified novel approach for correction of vaginal aplasia

OBJECTIVE To introduce a simple and easy surgical alternative for formation of a neovagina in patients with vaginal aplasia that offers reasonable anatomic and functional results. DESIGN Case series. SETTING University hospital. PATIENT(S) Three patients with complete vaginal aplasia without uterus. INTERVENTION(S) A silicone Foley catheter loaded into distal end of a fine needle and passed extraperitoneally into the space of Retzius followed by its inflation and traction for 8 days. MAIN OUTCOME MEASURE(S) Operative time, complication rate, reintervention rate, width and length of the newly formed vagina, and postoperative feasibility of intravaginal sexual intercourse. RESULT(S) The results were satisfactory: normal length and width of neovagina, no complications, and normal sexual life within 7 to 8 days after surgery. CONCLUSION(S) Fine needle vaginoplasty is a simple, fast, safe, and available extraperitoneal procedure for correction of vaginal aplasia. It can be done easily by any gynecologist aware of the anatomy of the retropubic space.

Modified Hysteroscopic Myomectomy of Large Submucous Fibroids

Objective: To compare the efficacy, feasibility, operative time and possible complications of a modified technique of hysteroscopic removal of large submucus myomata versus traditional morcellation technique, and to assess the efficacy of preoperative sonohysterography (SHG). Design: A prospective comparative study. Setting: Gynecologic Endoscopy Unit, Assiut University Hospital, Assiut, Egypt. Subjects: One hundred forty-two women of childbearing age with a clinical and transvaginal sonographic diagnosis of large solitary submucous myomata (>3 cm in diameter) with or without an intramural element. Interventions: The patients were divided into two groups. In group A (65 patients), a modified resectoscopic technique was used where the base of the myoma was excised followed by ring forceps extraction after misoprostol priming. In group B (77 patients), the myoma was cut using traditional resectoscopic morcellation. Main Outcome Measures: For each patient, operating time, intra- and postoperative complications and feasibility of the procedure were recorded. The accuracy of preoperative SHG in localizing submucous myoma and detecting intramural extension was assessed by diagnostic hysteroscopy. Results: Transvaginal SHG showed good agreement with hysteroscopy in localizing submucous myomata and detecting intramural extension (k = 0.83). The operating time was significantly shorter in group A (15.6 ± 3.02 min) than in group B (28.9 ± 4.3 min). The procedure was completed in 60 (92%) and 51 patients (66%), whereas a second session was required in 2 (3%) and 20 patients (25.9%) in both groups respectively. Glycine volume was highly significantly less in group A (2.3 ± 0.86 vs. 6.3± 1.7 liters, p = 0.001). Intraoperative complications were encountered in 9 (13.8%) and 22 patients (28.5%) in both groups respectively (p = 0.03). Cervical laceration was diagnosed in 3 cases (4.6%) in group A. Postoperative visual disturbances were diagnosed in 4 cases (5%) in group B. Conclusions: Hysteroscopic resection of large submucous myomata with minimal intramural encroachment is feasible using a modified technique. It shows a minimal complication rate and fluid deficit and a shorter operative time than the standard morcellation technique. If the excised myoma is extracted as one mass, this carries a minimal risk of cervical lacerations and possible cervical incompetence in a subsequent pregnancy. Transvaginal SHG is a reliable diagnostic aid to assess submucous myomata.

Laparoscopic myomectomy: Sonographic follow-up and second-look laparoscopy for the evaluation of a new technique

Between 1988 and 1993, 100 women underwent laparoscopic myomectomy in the Department of Obstetrics and Gynecology of the University of Ulm. Indications varied, although most myomectomies were done for fertility enhancement or preservation. Closure of the incision, especially with an open uterine cavity, was done in two or three layers. Several technical limitations specific to laparoscopic surgery impair complete and satisfactory closure of the myomectomy incision. In this study we evaluate the new technique by sonographic control and second-look laparoscopy. In 22 cases second-look laparoscopy was undertaken to assess post-operative adhesion formation and to effect adhesiolysis. The rate of adhesion formation was 28%, depending on site, size, and number of myomas. Adhesion formation was significantly higher (p<0:005) in myomas located on the posterior wall. The density of adhesions did not vary significantly. In 22 cases sonography was done preoperatively, one day after the operation and 6 weeks postoperatively to compare wound healing, depending on myoma site and size. In 74% of cases an intramural hematoma of varying size was observed. By the third control, 6 weeks later, an irregular hypodense area was seen in only 8%. This study demonstrates that laparoscopic myomectomy entails the risks of postoperative adhesion formation and impaired wound healing, including intramural hematoma. So far no data are available showing a correlation between these risks and post-operative infertility or higher incidence of uterine rupture.

Ovarioscopy, a technique to determine the nature of cystic ovarian tumors.

STUDY OBJECTIVE To test the value of ovarioscopy as an additional step in the diagnostic work-up of probably benign cystic ovarian tumors before laparoscopic intervention, and to compare its diagnostic accuracy with that of transvaginal ultrasonography (TVUS) and tumor markers. DESIGN Cross-sectional study (Canadian Task Force classification II-2). SETTING Gynecologic endoscopy unit at a university hospital. PATIENTS Sixty-eight women with unilateral or bilateral ovarian cystic swellings without clinical, sonographic, or laparoscopic suspicion of malignancy. INTERVENTION Preoperatively, TVUS and tumor markers were estimated. Intraoperative endocystic ovarioscopic visualization ovarioscopy and ovarioscopy-guided biopsy were done before laparoscopy. MEASUREMENTS AND MAIN RESULTS Ovarioscopy had the highest specificity for detecting benign ovarian cysts (98%) compared with (72.6%) and (72%) for tumor markers and TVUS, respectively. Its positive predictive value was 50% compared with 5% and 6% for tumor markers and TVUS, respectively. Its findings agreed with the histopathologic diagnosis in 39 patients (57%, p = 0.000, k = 0.85). CONCLUSION Ovarioscopy is a simple, rapid maneuver that should precede laparoscopic ovarian cystectomy. It is superior to tumor markers and TVUS for predicting the benign nature of ovarian cysts.