Dolores Foth

Conservative treatment of ectopic pregnancy in a cesarean section scar with methotrexate: a case report

Ectopic pregnancies sited in dehiscent cesarean section scars have a high risk of rupture and bleeding. Attempts at operative therapy frequently end in loss of the uterus. A connection with the cavum uteri justifies an attempt at dilatation and curettage. We describes a patient with combined systemic and local intra-amniotic methotrexate (MTX). The uterus was preserved.

Pre- and postoperative hormonal treatment in patients with hysteroscopic surgery.

Hysteroscopic surgery is widely used for the treatment of patients suffering from infertility and menorrhagia. Preoperative and postoperative treatment plays an important role in this kind of surgery. The indications for hormonal pre- and postoperative treatment are very different and depend on the type of surgery and the condition of the patient. For a septum dissection, preoperative treatment is not necessary. Postoperative estrogen therapy can be helpful especially after dissection of a large septum. For intrauterine adhesiolysis, preoperative treatment is without benefit. In cases of adhesions of grades 3 and 4, postoperative treatment entailing insertion of an IUD and application of estrogens for about 3 months is recommended. A higher amenorrhea rate after endometrium ablation can be reached by pretreatment with a GnRH analogue or danazol. For resection methods, pretreatment is not necessary in any case. The success rate of endometrium ablation (reduction of blood loss) is not influenced by pretreatment. Pretreatment can be useful in coagulation techniques in patients suffering from secondary anemia and in high-risk patient. In patients who need hormone replacement therapy after endometrium ablation, gestagen application is necessary. For prevention of bleedings, a continuous combined hormone replacement therapy should be used and so a bleeding-free treatment is possible. The residual endometrium will so be protected against hyperplasia. Another alternative postoperative method after endometrial ablation is insertion of a levonorgestrel IUS. Our studies show advantages for protection of the endometrium, for contraception and a high amenorrhea rate. Prior to a hysteroscopic myoma resection, pretreatment with GnRH analogues is indicated for all myomas with a diameter of more than 3 cm and/or an intramural portion or for patients suffering from secondary anemia. The aim of the pretreatment is not only to obtain a thin endometrium but also to reduce the size and vascularization of the myomas. The failure rate in patients not treated with GnRH analogues is higher especially in large intramural myomas. Pre- and postoperative hormonal treatment can be effective, especially in the treatment of patients suffering from menorrhagia. The indications for hormonal pre- and postoperative treatment should be very strong. A hysteroscopic surgeon should be also have some experience in hormonal treatment.

Prognostic value of repeated serum CA 125 measurements in first trimester pregnancy

OBJECTIVE To assess the diagnostic value of maternal CA 125 in patients with symptomatic first trimester pregnancy and to evaluate the prognostic significance of CA 125 versus beta-hCG in early pregnancies with intact fetal heartbeat, complicated by vaginal bleeding. STUDY DESIGN Two prospective open-label studies with longitudinal follow-up in the second trial. SETTING Academic Department of Obstetrics and Gynecology, University of Cologne. PATIENTS Study 1: 168 patients presenting between gestational weeks 6 and 12 with: extrauterine pregnancy, 29; missed abortion, 50; incomplete spontaneous abortion, 38; imminent abortion, 33; and normal pregnancy (no history of endometriosis or ovarian mass), 18. Study 2: Fifty consecutive patients with vaginal bleeding during gestational weeks 6-12 all of whom having demostrable fetal heartbeat. Eighteen patients finally aborted whereas the remainder had normally continuing pregnancy until term. MAIN OUTCOME MEASURE Study 1: Single serum determinations of CA 125 and beta-hCG were correlated with the different disorders observed. Study 2: Two sequential measurements of serum CA 125 and beta-hCG performed within a 5-7 days interval were related to the outcome of pregnancy as indicated by changes of the ultrasound presentation, miscarriage, future hospitalization, or delivery. RESULTS Study 1: Patients with vaginal bleeding generally had higher median CA 125 values (38 IU/ml; range 1.3-540) compared to non-bleeding patients (17.8 IU/ml; range 1.0-157). No statistically significant differences in regard to median serum CA 125 levels between symptomatic and normal pregnancies occurred: normal pregnancy, 25.5 IU/ml (range 3.2-97); ectopic pregnancy, 26 IU/ml (range 1.3-157); missed abortion, 19.1IU/ml (range 1-242); threatened abortion, 48 IU/ml (range 5.2-540); spontaneous abortion, 40 IU/ml (range 5.4-442). Study 2: Initial CA 125 levels did not differ significantly between both groups of patients with 27/32 non-aborters and 13/18 aborters showing concentrations below 65 IU/ml. After 5-7 days, CA 125 in all patients who eventually aborted remained high or increased whereas non-aborters all had constantly low or steeply declining CA 125 measures. beta-hCG increased in all non-aborters but also in 13/18 aborters during the 5-7 day interval. CONCLUSION Single serum measurements of CA 125 in symptomatic first trimester pregnant patients failed to discriminate spontaneous abortion, ectopic or normal pregnancies. However, sequential determinations of maternal CA 125 measurements appear to be a highly sensitive prognostic marker in patients with viable pregnancy at risk for abortion.

Is it possible to recommend an ‘optimal’ postoperative management after hysteroscopic metroplasty? A retrospective study with 52 infertile patients showing a septate uterus

Background. The aim of the retrospective study was to evaluate the ‘optimal’ postoperative management after hysteroscopic metroplasty.

Minihysteroscopy as Routine Diagnostic Procedure in Women With Primary Infertility

STUDY OBJECTIVE To evaluate the importance of routine minihysteroscopy in the diagnosis of primary infertility. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING Endoscopic center at a university hospital. PATIENTS Three hundred seventy-nine patients with primary infertility. INTERVENTION Diagnostic minihysteroscopy without anesthesia or sedation. MEASUREMENTS AND MAIN RESULTS Hysteroscopy was normal in 337 patients (89.9%). In 38 patients (10.1%) an intrauterine pathology was found: 26 intrauterine adhesions, 12 cases of uterus subseptus. The procedure could not be completed in four women. CONCLUSION Minihysteroscopy should become a routine diagnostic procedure in women with primary infertility, even those with no suspected intrauterine pathology or other risk factors.

Results of a prospective comparative study of transvaginal hydrolaparoscopy and chromolaparoscopy in the diagnostics of infertility.

Transvaginal hydrolaparoscopy (THL) was evaluated in comparison with the already established chromolaparoscopy in the detection of tubal factors, adhesions as well as endometriosis. 43 infertile patients without previous pelvic operations and with an inconspicuous clinical examination were included in a prospective comparative study of THL and chromolaparoscopy. THL succeeded in 40 patients (93.0%). Both methods showed 100% agreement with regard to tubal factors and adhesions. However, only 72/80 tubes (90.0%) could be portrayed by THL. In contrast to this, THL failed to identify 8 of 10 laparoscopically verified endometrioses (isolated endometriosis of the bladder peritoneum in 2). No complications occurred with THL. THL could be the method of choice for the clarification of mechanical infertility factors in symptom-free patients with no suspicion of pelvic pathologies. Tubal pathologies and/or adhesions (visible during THL) should be indications for laparoscopy. In the case of inconspicuous genitals during THL and a still unfulfilled desire for offspring postoperatively, laparoscopy should be considered in order to exclude the possibility of unidentified endometriosis. Retroflexio uteri should at least be a relative contraindication for THL. Further studies are necessary to evaluate the role of THL in the diagnostic concept of infertility in the future.

Prolactin Serum Levels in Postmenopausal Women Receiving Long-Term Hormone Replacement Therapy

In the literature there are different opinions about serum prolactin levels after the menopause and in women using hormone replacement therapy. We report serum prolactin levels of 165 women after surgical or natural menopause who received different kinds of hormone replacement therapies over 2 years and 6 months. Surgically or naturally menopausal women showed no significant differences in serum prolactin levels. After starting hormone replacement therapy, the serum prolactin levels decreased. During subsequent treatment cycles, serum prolactin showed varying levels within the reference limits. Women using hormone replacement therapy developed no new manifestation of hyperprolactinemia.

Effect of Soy Supplementation on Endogenous Hormones in Postmenopausal Women

Aim: The purpose of this study was to investigate the effect of soy supplementation with isoflavones on plasma hormone levels in postmenopausal women. Methods: 16 postmenopausal women (mean age 56.21 ± 5.01 years) were assigned to 24 weeks of dietary soy supplementation. A defined soy protein amount per day (20 g) with a low dosage of isoflavones (20 mg) was used. Plasma samples were analyzed for estradiol, FSH, LH, prolactin, testosterone and DHEAS. Results: After 24 weeks of soy supplementation, plasma levels of estradiol did not increase. Gonadotropins, prolactin and the measured plasma androgens remained unchanged. We did not see any significant treatment effects. Conclusions: In the postmenopausal hypoestrogenic situation, soy protein consumption with low isoflavones does not influence endogenous hormone levels of estradiol and gonadotropins.

Viability of human ovarian tissue confirmed 5 years after freezing with spontaneous ice-formation by autografting and chorio-allantoic membrane culture

To achieve optimal and uniform outcomes, slow cooling protocols for human ovarian tissues generally initiate ice formation at high sub-zero temperatures (-6 to -9 °C). The aim of the study was to investigate the function of ovarian tissue that had unintentionally self seeded at -20 °C during the freezing step, by examining its development following chicken embryonic chorioallantoic membrane (CAM) grafting and after transplantation back to the patient. Ovarian tissue was frozen in 6% (v/v) dimethyl sulfoxide, 6% (v/v) ethylene glycol and 0.15M sucrose which had self-seeded at -20 °C. Five years after cryopreservation, 8 pieces were thawed and transplanted back to the patient. Two small (1 × 2 × 1 mm) pieces of this thawed tissue were cultured in a CAM-system for 5 days to assess the tissue viability. The autografted ovarian tissue re-established spontaneous menstrual bleeding within five months and raised serum 17-β Estradiol from 19 to 330 pg/ml. Ultrasound revealed a dominant follicle at the site of the transplanted tissue in the follicular phase after the menstrual bleed. Analysis of the CAM cultured tissue established that 88% of the primordial follicles are degenerated and there was limited in growth of blood vessels. In conclusion, in spite of the damage caused by the cryopreservation with spontaneous ice-formation the viability could be confirmed by CAM culture and the restoration of ovarian function after auto-transplantation.

Glycodelin serum levels in women with ectopic pregnancy

OBJECTIVE Aim of our study was to determine circulating levels of glycodelin for biochemical monitoring of women with vaginal bleeding and/or abdominal pain in early pregnancy. The objective was, using glycodelin as a biochemical parameter, to distinguish between incomplete abortion and ectopic pregnancy in early weeks of gestation. STUDY DESIGN In 169 women with a first trimester pregnancy, a single serum measurement of maternal glycodelin was taken. Patients were divided into groups according to the clinical and/or ultrasonografic findings at the time of hospitalisation:ectopic pregnancy, incomplete abortion and control. RESULTS Glycodelin serum levels were significantly lower in patients with ectopic pregnancy comparable with intact pregnancy and incomplete abortion. There was no difference in serum levels between intact pregnancy and incomplete abortion. CONCLUSION Glycodelin might represent a biochemical parameter in the differential diagnosis between ectopic pregnancies and incomplete abortion. The number of patients was too small to give reference ranges for pregnancy weeks.