Dov Feldberg

Femoral neuropathy subsequent to abdominal hysterectomy. A comparative study

Abstract In a prospective study of two 5-yr periods two groups of patients undergoing pelvic operative procedures were compared. Iatrogenic femoral neuropathy occurred in 282 patients who underwent pelvic abdominal surgery in the first group of women, an overall incidence of 7.45%. The neuropathy was associated with the use of self-retaining retractors during surgery. Femoral nerve neuropathy occurred only in two patients in the second group in whom no retractors were used during operation. No other contributing factors were found. The duration of complaints ranged from 3 to 90 days. Spontaneous recovery occurred in 265 patients, while in 17 there were residual mild symptoms for up to 116 days. No serious sequelae have been observed. Prevention of this mostly mild yet annoying syndrome may be achieved if no retractors are used in gynecological operations, or, if they are necessary, due to difficult conditions at surgery or if the operation is long, they should be used with care and loosened from time to time. It is estimated that the incidence of iatrogenic femoral nerve neuropathy is higher than reported, since in very mild cases the patient fails to mention her complaints. The prognosis is usually rather good.

Ovarian cyst formation: a complication of gonadotropin-releasing hormone agonist therapy.

Since gonadotropin-releasing hormone (GnRH) analogs were introduced into clinical therapeutic use, several side effects directly related to the hypoestrogenic state have been reported. The authors have encountered a rather infrequent complication, namely ovarian cystic formations, when using these compounds for selected in vitro fertilization and embryo transfer (IVF-ET) cases. In 7 of 24 patients with Decapeptyl (D-Trp6-luteinizing hormone-releasing hormone [LH-RH], Ferring, Kiel, FRG) treatment, and in 5 of 22 patients treated with Buserelin (Superfact, Hoechst A.G., Frankfurt, FRG), solitary ovarian cysts developed during the down-regulation phase. Their growth did not change during ovulation induction with menotropins. Although the mechanism of ovarian cyst formation during GnRH agonist treatment is not clear, their presence does not appear to interfere with the fertility of these women.

Spontaneous abortion in patients with insulin-dependent diabetes mellitus: The effect of preconceptional diabetic control

Fifty-nine of 94 pregnant women with juvenile-onset insulin-dependent diabetes who attended a preconceptional clinic were periodically examined by a diabetologic team. Glycemic control was obtained by intensified insulin therapy and monitored by blood glucose self-monitoring. These women were compared with the 35 pregnant women who did not receive preconceptual glycemic control. The initial glucose and maternal hemoglobin A1 values of the latter group experiencing spontaneous abortions were significantly higher (p less than 0.001) when compared with women receiving preconceptional diabetologic counseling whose pregnancies continued beyond 22 weeks gestation. The frequency of spontaneous abortions among patients not seen before pregnancy was significantly higher (p less than 0.001), in contrast to attending women, whose rate represented the normal rate in the general population. We confirm the evidence accumulated in the recent literature that poor metabolic control around conception and in the early weeks of pregnancy may be the determining factor favoring abortion.

Transvaginal ultrasonic needle-guided aspiration of endometriotic cysts before ovulation induction for in vitro fertilization

Controversy still exists concerning the optimal treatment of endometriomata in endometriosis and its related infertility. Forty-one women with endometriomata who failed to conceive during previous in vitro fertilization and embryo transfer (IVF-ET) cycles (protocol A) were readmitted for ovum pickup following transvaginal ultrasonic needle-guided aspiration of the endometriomata (protocol B). Following aspiration a significantly higher number of oocytes was recovered (P<0.0006); subsequently, more embryos were transferred, and significantly higher clinical pregnancy rates per cycle (P<0.0001) were achieved. This difference may be directly related to the reduction of extensive ectopic endometrial tissue (endometriomata) with improved ovarian response, follicular accessibility, and most probably, improved oocyte quality.

Age and pregnancy rates in in vitro fertilization

The influence of women[s age on the results of in vitro fertilization (IVF) was analyzed in 1801 women undergoing the procedure. Advancing age was found to be related to significant reduced success rates from an average of 30.1% per transfer below the age of 36 years to 15.9% per transfer at 37 years or more (P<0.001). The decrease was related to a reduction in oocyte production (five at 25 years or less, four below the age of 40 years, three at 40 years or more, and two in the 43 to 47-year group) and probably-due to reduced implantation. It is concluded that a womans age must be considered an important prognostic factor when IVF is suggested.

The impact of high progesterone levels in the follicular phase of in vitro fertilization (IVF) cycles: A comparative study

Estrogen (E2) and plasma progesterone (P4) levels are valuable parameters for follicular development in in vitro fertilization (IVF) cycles. Furthermore, the progesterone concentration prior to, during, and following human chorionic gonadotropin (hCG) administration is an important marker for the detection of early luteinization and premature ovulation. The pattern of hormonal profile in relation to the number of oocytes retrieved, fertilized, and cleaved and the fate of the pregnancies achieved were compared in three groups of patients treated by the same protocol. Group I included 22 women who conceived with high progesterone levels on day hCG+1 (P4>2.5 ng/ml). Group II included 43 women who conceived with low P4 values (P4<2.5 ng/ml), while group III included 46 patients in whom no pregnancies occurred. A significant decrease in fertilization, cleavage, and pregnancy rates was observed in patients with high progesterone levels on day hCG+1, compared to those with normal levels. Nevertheless, it is suggested that cycles with high P4 levels in the preovulatory phase should not be canceled, as a fair chance for pregnancy still exists.

The value of hysteroscopy in elderly women prior to in vitro fertilization-embryo transfer (IVF-ET): A comparative study

Two hundred eighty-four hysteroscopies were performed in 312 (91%) candidates for in vitro fertilization and embryo transfer (IVF-ET) who were divided into two groups. Group I consisted of elderly women over 40 years, and group II of women below this age. Although visualization revealed uterine abnormalities in 29.9% of all patients, abnormal findings were significantly increased in the former group in comparison to the latter (P<0.001). This difference was attributed mainly to uterine rather than cervical pathology. Furthermore, in elderly women agerelated uterine pathology such as submucous myomata, endometrial hyperplasia, and polyps were more prominent, while in younger patients other uterine lesions such as adhesions and tubal ostia occlusion were more common. Moreover, treatment prior to IVF-ET resulted in 7 clinical pregnancies (8.9%) in group I and in 41 clinical pregnancies (19.9%) in group II, all of which failed in one to three cycles previously. It seems that hysteroscopic evaluation may reduce the IVF-ET failure rate due to intrauterine abnormalities in elderly as well as young patients, thus it becomes an absolute prerequisite for all patients scheduled for an IVF program.

Intrapartum Management of Insulin-Dependent Diabetes Mellitus (IDDM) Gestants: A comparative study of constant intravenous insulin infusion and continuous subcutaneous insulin infusion pump (CSIIP)

Two groups of insulin-dependent diabetes mellitus (IDDM) parturients were managed according to different intrapartum protocols and compared with a control group of normal women in labor. Thirty-seven patients received conventional intensified insulin therapy during pregnancy and intravenous continuous insulin infusion during labor. Twenty-eight women were managed by continuous subcutaneous insulin infusion pump (CSIIP) throughout gestation and this therapeutic approach was continued during labor. When the two glucose control techniques were compared, CSIIP was superior to achieving and maintaining intrapartum optimal metabolic control, reducing significantly the incidence of acute fetal distress, thus lowering the cesarean section rate and neonatal hypoglycemia. Consequently we concur with the recommendation that firm prepartum as well as intrapartum diabetic control is mandatory for successful management of labor in IDDM patients.

Fetal surveillance in insulin-dependent diabetic pregnancy: Predictive value of the biophysical profile

Ninety-eight insulin-dependent diabetic pregnancies underwent monitoring by means of 978 biophysical profiles from 28 weeks gestation until parturition. Only 2.9% of the 978 tests had abnormal results (score ⩽7). When performed within 2 days before birth, a normal biophysical profile predicted the 1-minute Apgar score to be normal in 92% and 5-minute Apgar score in 99%. When all biophysical profiles ever performed were included, the predictive value improved to 100%. The babys first cry within 1 minute after birth was predicted in 95%. Furthermore, the predictive value of a normal biophysical profile regarding the absence of ominous intrapartum cardiotocographic patterns was excellent (95%). The specificity was in general good (80% to 90%), but the predictive value of abnormal test results and sensitivity were almost without exception poor. It seems that the very low rate of abnormal biophysical profiles indicates that obstetric interventions were made immediately after the occurrence of the first sign of fetal jeopardy; thus improved results were obtained.

Abdominal complications following ultrasonically guided percutaneous transvesical collection of oocytes for in vitro fertilization

Ultrasonically guided transvesical oocyte aspiration is a safe and efficient method in most in vitro fertilization (IVF) units. It entails very rare severe complications, even though transvesical punctures performed may unintentionally pierce the bowel or even major blood vessels. Nevertheless, mild complications are rarely noted and reported. During a 9-month period 140 ovum pickups were performed: 102 by transabdominal ultrasound-guided puncture and 38 by means of laparoscopy. In the former group, abdominal pain (11.6%), exacerbation of previous pelvic inflammatory disease (2.9%), mild hemoperitoneum (2.9%), urinary tract infections (5.8%) and transient macroscopic hematuria (5.8%) occurred following the procedure. In the latter group, abdominal pain followed in 7.8%; no urinary tract complications were noted in women undergoing laparoscopic ovum aspiration. In spite of the fact that ultrasonically guided transvesical oocyte collection is an atraumatic method with rare complications, they should be reported in order to draw attention to their not-so-rare occurrence and with the aim of their prevention.