Bo Lindblom

Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy*

OBJECTIVE Women with ectopic pregnancy (EP) who have been operated on by laparoscopy are thought to have improved subsequent fertility, probably because of less adhesion formation. We aimed to evaluate the adhesion formation after laparoscopy as compared with laparotomy in a randomized trial. DESIGN One hundred five patients with tubal pregnancy were stratified with regard to age and risk factors and randomized to surgery by laparoscopy or laparotomy. To evaluate adhesion formation and tubal status, 73 patients with strong desire of pregnancy underwent a second-look laparoscopy. The adhesion status at the ipsilateral and contralateral side at primary surgery was compared with the status at second-look laparoscopy. RESULTS Patients operated on by laparotomy developed significantly more adhesions at the operated side than patients operated on by laparoscopy (P less than 0.001). Substantially more patients in the laparotomy group underwent adhesiolysis at second-look laparoscopy than did patients in the laparoscopy group. Tubal patency did not differ between the groups. CONCLUSIONS Laparoscopic treatment of EP results in less impairment of the pelvic status compared with conventional conservative surgery.

Laparoscopic surgery in ectopic pregnancy : a randomized trial versus laparotomy

A randomized, prospective clinical trial was conducted to compare the efficacy of laparoscopic treatment with conventional conservative abdominal surgery for tubal pregnancy. Entry criteria were: size of the ectopic gestation < 4 cm, hemodynamic stability, accessibility for laparoscopic treatment and a trained laparoscopist on duty. There was no difference between the groups regarding gestational duration, size and location of the ectopic gestation, or the mean preoperative hCG values. The groups differed with respect to total operation time (73 min for the laparoscopy group vs. 88 min for the laparotomy group), hospital stay (2.2 vs. 5.4 days) and convalescence period (11 vs. 24 days). The rates of elimination of hCG was similar in the groups, and there were no statistical difference in the rate of second intervention.

A cost-effectiveness study of a randomised trial of laparoscopy versus laparotomy for ectopic pregnancy

We compared the cost-effectiveness of therapeutic laparoscopy and open laparotomy for treatment of laparoscopically diagnosed ectopic pregnancy. Clinical outcomes of ectopic pregnancy treatment were based on results of a randomised trial done between 1987 and 1989 at Sahlgrenska University Hospital (Göteborg, Sweden). We estimated costs for inpatient and follow-up care of ectopic pregnancy by the two methods. Observed resource use (eg, procedure duration) was multiplied by 1992 estimates of resource unit cost (eg, cost per minute of laparoscopy time), based on detailed internal cost accounting data from Huddinge University Hospital. By specified criteria, the initial procedure eliminated trophoblastic activity without major complications in 81% (95% CI: 68-90) of 52 laparoscopy patients, versus 95% (85-99) of 57 laparotomy patients. Residual trophoblast or complications were successfully treated in all remaining patients. Mean simulated costs (standard error) for the overall laparoscopy strategy were 28,058 (1780) Swedish kronor versus 32,699 (1080) kronor for laparotomy (p = 0.03). In the baseline simulation and most sensitivity analyses, laparoscopy produced final outcomes equivalent to those of laparotomy at lower costs. As laparoscopic outcomes improve, this newer approach should become increasingly preferable.

Fertility outcome after conservative surgical treatment of ectopic pregnancy evaluated in a randomized trial

OBJECTIVE To evaluate the fertility outcome after laparoscopic surgery for ectopic pregnancy. DESIGN A randomized trial versus laparotomy was performed between May 1987 and June 1989. SETTING The study was conducted in a clinical university center, the Sahlgrens Hospital. PATIENTS A group of 105 patients with tubal pregnancy were stratified with regard to risk determinants and age and randomized to laparoscopy or laparotomy. Eighty-seven patients who desired pregnancy were evaluated for subsequent fertility outcome. INTERVENTIONS Linear salpingotomy was performed in both surgical groups. MAIN OUTCOME MEASURE We evaluated the fertility outcome after laparoscopic salpingotomy for comparison with the outcome after laparotomy. RESULTS There was no difference between the groups in the overall fertility outcome. A substantially higher proportion of patients in the laparotomy group were subjected to adhesiolysis performed at a second-look laparoscopy. CONCLUSIONS The fertility prospects are not impaired by laparoscopic surgery. Adhesiolysis at a second-look laparoscopy, especially after laparotomy, might be beneficial in selected cases and may serve to improve subsequent fertility.

LOCAL PROSTAGLANDIN F2α INJECTION FOR TERMINATION OF ECTOPIC PREGNANCY

Abstract In nine women with unruptured ectopic pregnancy, prostaglandin F 2α was injected under laparoscopic control into the affected oviduct and in eight patients also into the ovary containing the corpus luteum. Termination of the pregnancy was achieved in all cases (in one at the second attempt), without complications. Fertility after this procedure needs to be compared with that after conventional surgery.

Signaling Pathway of Nitric Oxide-Induced Acrosome Reaction in Human Spermatozoa

Abstract Nitric oxide (NO) has been recently shown to modulate in vitro motility, viability, the acrosome reaction (AR), and metabolism of spermatozoa in various mammalian species, but the mechanism or mechanisms through which it influences sperm functions has not been clarified. In human capacitated spermatozoa, both the intracellular cGMP level and the percentage of AR-positive cells were significantly increased after 4 h of incubation with the NO donor, sodium nitroprusside (SNP). SNP-induced AR was significantly reduced in the presence of the soluble guanylate cyclase (sGC) inhibitors, LY83583 and ODQ; this block was bypassed by adding 8-bromo-cGMP, a cell-permeating cGMP analogue, to the incubation medium. Finally, Rp-8-Br-cGMPS and Rp-8-pCPT-cGMPS, two inhibitors of the cGMP-dependent protein kinases (PKGs), inhibited the SNP-induced AR. Furthermore, SNP-induced AR did not occur in Ca2+-free medium or in the presence of the protein kinase C (PKC) inhibitor, calphostin C. This study suggests that the AR-inducing effect of exogenous NO on capacitated human spermatozoa is accomplished via stimulation of an NO-sensitive sGC, cGMP synthesis, and PKG activation. In this effect the activation of PKC is also involved, and the presence of extracellular Ca2+ is required.

Fertility after ectopic pregnancy in relation to background factors and surgical treatment

To study the importance of certain background factors and surgical treatment, the obstetric outcome in 205 women consecutively treated for ectopic pregnancy was analyzed by means of questionnaires 4 to 5.5 years after surgery. The response rate was 83.4% and, among women desiring pregnancy (n = 112), the total pregnancy rate was 75.9% and the delivery rate 53.6%. The total incidence of repeat ectopics was 27.3%, and the proportion of women who had a repeat ectopic pregnancy but no delivery was 20.5%. Six of seven women having an ectopic pregnancy with a copper intrauterine contraceptive device in situ had a normal delivery during the follow-up period. The subsequent fertility among nonresponders appeared lower than among responding women. A number of background factors present at the time of surgery were correlated to subsequent infertility, e.g., history of infertility and previous abdominal surgery. Conversely, there was no correlation between the fertility outcome and the type of operative procedure.

Contractile Patterns of Isolated Oviductal Smooth Muscle Under Different Hormonal Conditions

The isthmic portion of the human fallopian tube was excised during surgery and the ampullary-isthmic junction was identified. Muscle strips (1-mm wide) were dissected from the outer longitudinal and the inner circular layers at this region and used for isometric recordings of spontaneous contractile activity in organ bath experiments. It was found that the amplitude and the duration of individual contractions were similar during various phases of normal menstrual cycles, whereas the frequency of contractions was significantly increased during the periovulatory period in both circular and longitudinal muscle. During early pregnancy or treatment with combined oral contraceptives the motility pattern was similar to that observed in the late luteal phase, being characterized by a comparatively low contraction frequency. In the perimenopausal period, irregular patterns were frequently observed whereas preparations obtained from postmenopausal women exhibited a very weak activity with low amplitude and frequency of contractions. Similar activity was encountered in specimens from patients treated with androgens. It is concluded that endogenous estrogens stimulate human oviductal contractility while endogenous progesterone has a depressive action on tubal activity. Both effects occur with a certain delay and are prolonged for up to 3 days, i.e., the changes in the serum levels of ovarian steroids and the induced alterations of tubal contractility are out of phase.

Treatment of tubal pregnancy by laparoscope-guided injection of prostaglandin F2α*

Twenty-six cases of unruptured tubal pregnancy were treated by laparoscope-guided injection of prostaglandin (PG) F2α into the affected tube and the ovary containing the corpus luteum. Preoperative serum human chorionic gonadotropin (hCG) levels were 22 to 2,050 IU/L (mean 328 IU/L). The procedure was successful in 24 patients (92%), as indicated by reduction of hCG values to

Sex steroid receptors and human parturition

Objective To investigate the correlation between sex steroid hormones and their receptors during normal and dysfunctional labor. Methods Myometrial and decidual biopsies along with maternal and cord blood samples were taken from women with or without labor activity. Estrogen and progesterone receptor contents in myometrum and decidua were determined by enzyme immunoassay, and hormone concentrations were analyzed by radioimmunoassay. Results In the lowere segment of the uterus, the prosgesterone receptor concentrations of myometrum were significantly lower in oxytocin-resistant dystocia compared with those of normal labor and before labor (P < .04, P < .005. respectively). No significant difference was found in the estrogen receptors of myometrum from the upper segment showed higher concentrations in active labor compared with those before labor and oxytocin-resistant labor (P < .01, P < .05, respectively). Estrogen receptors from the upper segment showed no significant difference in these regards. The was no difference in peripheral and myometrial sex hormone levels in the groups studied. Conclusion These data suggest that, in the human, 1) oxytocin-resistant labor is associated with low levels of progesterone receptors, 2) estrogen receptors, 2) estrogen receptors content in myometrium might have no or little relation to labor, and 3) functional labor seems not to be related to a decreased progesterone activity in the myometrium.