Bruce G. Bateman

Complications of laparoscopy—operative and diagnostic *

OBJECTIVE To assess the characteristics and rates of complications for operative laparoscopy and diagnostic laparoscopy. DESIGN Retrospective review. SETTING Tertiary-care university hospital. PATIENTS Two thousand three hundred twenty-four patients undergoing operative laparoscopy or diagnostic laparoscopy. INTERVENTIONS Operative laparoscopy including lysis of adhesions, tubal surgery, ovarian surgery, uterine surgery, or destruction of endometriosis. MAIN OUTCOME MEASURES Complication rates for operative and diagnostic laparoscopies were tabulated and compared. RESULTS The overall major complication rate for this series of 2,324 laparoscopies was 0.22%. There were five major and 15 minor complications. In the operative laparoscopy group, there were more complications from Veress needle and trocar insertion (n = 15) than from the actual operative procedures (n = 3). There were more total complications in the operative laparoscopy group (n = 18) than in the diagnostic laparoscopy group (n = 3). CONCLUSION Operative laparoscopy is efficacious for a variety of gynecologic surgical procedures.

Endoscopic versus laparotomy management of endometriomas

OBJECTIVE To compare the surgical management and follow-up of patients with endometriomas managed by endoscopic surgery versus laparotomy using a retrospective case control format. DESIGN Endoscopic oophorocystectomies were performed on 36 patients. Chart review of laparotomy oophorocystectomies from 21 patients was conducted. Six-week and 12-month follow-up for evaluation of symptoms, evidence of recurrence, and fertility was available on all subjects. RESULTS In the endoscopy group, 39 patients had screening laparoscopy for possible endoscopic surgery. Three of this group required laparotomy and 36 patients underwent endoscopic surgery. Chart review identified 21 patients who had undergone primary laparotomy for endometriomas. Patient groups were matched for age, severity of disease, presence of other infertility factors, and absence of perioperative medical suppression. Outcome parameters for each group were: operating time--endoscopy 2.8 hours (+/- 1.2), laparotomy 3.1 hours (+/- 1.8); estimated blood loss--endoscopy 40 cc (+/- 45); laparotomy, 240 cc (+/- 107); recovery time--endoscopy, 6.2 days (+/- 2.5), laparotomy 30 days (+/- 6.8); endometrioma recurrence rate--endoscopy 11.1%, laparotomy 19%; and pregnancy rate--endoscopy 42.8%, laparotomy 46.6%. CONCLUSION A high percentage of patients with endometriomas associated with advanced endometriosis can be managed effectively by endoscopic surgery.

Exogenous estrogen therapy for treatment of clomiphene citrate-induced cervical mucus abnormalities: is it effective?

Clomiphene citrate (CC) may have an adverse effect on cervical mucus (CM) quality and quantity. A placebo-controlled study was performed to assess the effect of exogenous follicular phase estrogen (E) on CM. Subjects qualified for inclusion by repeated demonstration of poor CM while on CC therapy as judged by spinnbarkeit, quantity, and viscosity. Subjects were treated by a randomized, placebo-controlled format using: (1) oral micronized estradiol (E2), 2 mg; (2) conjugated Es, 5 mg, or (3) placebo administered on cycle days 9 to 14. Cervical mucus was scored blindly during therapy within 48 hours before ovulation. Twelve subjects were observed through 36 treatment cycles with mean (+/- SD) CM scores: micronized E2, 4.2 +/- 1.8; conjugated Es, 4.3 +/- 1.7; and placebo, 4.7 +/- 2.9. There was no significant difference in mean values (P = 0.96, analysis of variance) or frequency of CM score greater than 4 (P = 0.85, Fisher exact test). We conclude that therapy with the E preparations tested did not improve the quality or quantity of CM in CC-treated patients.

Oocyte retention after follicle luteinization

Indirect evidence supports the existence of the luteinized unruptured follicle syndrome in infertile women. To seek direct evidence of oocyte retention, infertile and normal women were studied in the early and midluteal phase by visual documentation of ovulation stigma, needle aspiration of ovarian follicles, and peritoneal fluid collection for estradiol and progesterone assay. Luteal phase was confirmed by endometrial biopsy (postovulation day 2 to 8). In normal control subjects (n = 16), 25% of test cycles were stigma-negative and no oocytes were recovered. In infertile group (n = 23), 43% of test cycles were stigma-negative. Five oocytes were recovered including one from a stigma-bearing follicle. Peritoneal fluid steroid levels failed to discriminate stigma-positive from stigma-negative cycles in either group. Oocyte retention after luteinization occurs in infertile women.

Intravasation During Hysterosalpingography Using Oil-Base Contrast Media *

The use of oil-base contrast media for hysterosalpingography provides detailed imaging and the added information of a delayed film. Intravasation with possible embolization of oily media is often cited as a morbid complication. There are reports of significant morbidity associated with the use of high-viscosity oil media such as Lipiodol. Ethiodol has a significantly lower viscosity than Lipiodol. The incidence of intravasation can be reduced by proper timing of the study and avoidance of excessive pressures during instillation. With fluoroscopy, the early manifestations of intravasation can be detected, allowing the operator to limit the volume of embolized medium. We report 13 cases of intravasation (6 with embolization) with no morbidity during hysterosalpingography performed with Ethiodol. These data suggest that embolization of low-viscosity oil contrast media in low volumes is a relatively benign process. The text of this paper contains data on the clinical histories and courses of the 13 cases cited.

Subclinical pregnancy loss in clomiphene citrate-treated women

OBJECTIVE To ascertain the subclinical pregnancy loss rate in clomiphene citrate (CC)-treated infertile women compared with women of normal fertility. DESIGN Following a prospective format, serum samples were taken during the luteal phase of 92 menstrual cycles associated with CC treatment and 47 cycles in normal women. Human chorionic gonadotropin (hCG) assay sensitivity was 0.25 IU/L. Human chorionic gonadotropin assay was validated against 95 nonpregnant cycles. Criterion for pregnancy was a single serum sample greater than or equal to 0.5 IU/L. SETTING All subjects were under clinical management at the University of Virginia Health Sciences Center. PATIENTS AND PARTICIPANTS Patients undergoing CC induction of ovulation with satisfactory ovulatory response were candidates for the study group (n = 34). Control subjects of proven normal fertility were recruited (n = 22). Nonpregnant control subjects were sexually abstinent or had been surgically sterilized (n = 89). INTERVENTION A serum sample was taken during the late luteal phase of all subjects. RESULTS Thirteen percent of CC-treated cycles and 4.3% of normal control cycles were subclinical losses (P = 0.09). Fifty percent of CC-induced pregnancies were subclinical losses compared with 16.6% of normal control pregnancies (P = 0.05). Of CC patients who had at least one subclinical loss 47.6% later conceived a term pregnancy compared with 15.3% who did not have a subclinical loss (P = 0.06). CONCLUSION Subclinical pregnancy loss is more common in CC-treated women than normal women and may be a predictor of subsequent normal conception.

Homologous insemination—Revisited

Between July 1, 1969, and December 31, 1983, 1774 patients were evaluated in the private infertility clinic at the University of Virginia Hospital. Homologous artificial insemination was performed in 158 patients for the following indications: male factor (75.3%), cervical factor (16.7%), sperm deposition problem (3.7%), patients request (2.5%), and immunologic factor (1.8%). Whole-ejaculate insemination was performed in 68 patients; split ejaculates were used in 90 women. Additional fertility factors in 140 patients included endometriosis, anatomic abnormalities, and ovulatory difficulties. Of the 158 women, 23 (14.6%) had a total of 27 pregnancies (mean number of cycles, 5.7); 135 failed to conceive during treatment with homologous artificial insemination (mean number of cycles, 8.4). Most pregnancies (70.4%) occurred in those patients in whom homologous artificial insemination was used for a male factor. Among the 135 couples who failed to conceive with homologous artificial insemination, 20 (14.8%) patients subsequently had 25 pregnancies. Male factor had been the indication for homologous artificial insemination in 72% of the couples. Pregnancy outcomes were similar in all subgroups. Homologous artificial insemination may not be indicated for male factor-related infertility.

Utility of the 24-hour delay hysterosalpingogram film

Controversy exists regarding the ideal contrast media for hysterosalpingography. A unique property of oil-base contrast media is the availability of a 24-hour delay radiograph for further assessment of tubal patency and adhesions. A review was undertaken of the delay films in 131 cases performed by use of oil-base contrast media with subsequent surgical confirmation of pelvic findings. A 97% predictive accuracy was achieved with regard to distal obstruction and a 79% accuracy with regard to pelvic adhesions. Objective criteria for the evaluation of 24-hour delay hysterogram films were developed and are illustrated.

Serum amylase isoenzymes in ectopic pregnancy.

In general, significant amylase elevation was not documented in women with tubal pregnancies, compared with normal IUPs in the first trimester and a nonpregnant control range. One of 49 samples in 25 patients with tubal pregnancy was mildly elevated for salivary amylase.

Reproductive considerations during abdominal surgical procedures in young women.

The state of the art in reproductive technology is changing so rapidly that the future is hard to predict. In this regard, surgeons performing abdominal procedures in young women must be aware of the adverse reproductive effects of common surgical procedures. They should adopt changes in technique and practices to reduce adhesion formation. They should also be aware of the contemporary approach to the management of the various forms of tubal pregnancy and ovarian tumors of low malignant potential or of germ cell origin. The availability and success of changes in reproductive technology should lead to a reappraisal of the indications for hysterectomy, especially in young women. If there are indications for surgical excision of the ovaries and oviducts, the decision to remove the uterus should be made separately. The indication for hysterectomy needs to be very carefully considered, and the patients input is critical.