Erling Ekerhovd

The management of pelvic abscess

The optimum treatment for pelvic abscess would be an approach that is safe, efficacious, cost-effective, minimally invasive, and which affects the womans fertility potential as little as possible. In women of reproductive age tubo-ovarian abscess is one of the most common types of pelvic abscess. Tubo-ovarian abscesses are classically treated with broad-spectrum antibiotics. Frequently this approach fails and surgical intervention becomes necessary in about 25% of all cases. Surgical procedures include laparotomy or laparoscopy with drainage of abscess, unilateral or bilateral salpingo-ophorectomy, and hysterectomy. However, surgery for tubo-ovarian abscess is often technically difficult and associated with complications. An alternative approach is the use of imaging-guided drainage of abscess in combination with antibiotics. Combined data from several studies indicate that ultrasound-guided transvaginal drainage with concomitant antibiotics is especially safe and efficacious. This chapter discusses the management of pelvic abscess with a special focus on transvaginal ultrasound-guided drainage of tubo-ovarian abscess.

Testicular ultrasonography and extended chromosome analysis in men with nonmosaic Klinefelter syndrome: a prospective study of possible predictive factors for successful sperm recovery.

OBJECTIVE To investigate whether extended chromosome analysis or testicular sonography, including flow Doppler imaging, before diagnostic testicular sperm extraction have predictive value for successful sperm retrieval in men with nonmosaic Klinefelter syndrome. DESIGN Prospective clinical study. SETTING IVF clinic and genetics laboratory at a university hospital. PATIENT(S) Nineteen patients with nonmosaic Klinefelter syndrome and azoospermia. INTERVENTION(S) Collection of blood samples; histopathologic examination of testicular tissue; fluorescence in situ hybridization; sonography, including Doppler imaging; and testicular sperm extraction. MAIN OUTCOME MEASURE(S) Testicular volume, serum FSH and serum testosterone levels, percentage of normal XY cells, ultrasound echogenicity, intratesticular blood flow resistance, and sperm recovery. RESULT(S) Testicular volume and levels of serum FSH and serum testosterone levels did not differ significantly. No differences in testicular echogenicity or intratesticular blood flow resistance were found between 47,XXY men in whom sperm recovery was successful and those in whom sperm recovery failed. Significant differences were seen between all patients with the Klinefelter syndrome and controls with normal sperm values. Fluorescence in situ hybridization of peripheral lymphocytes and buccal tissue showed no correlation between frequency of normal 46,XY cells and testicular spermatogenesis. CONCLUSION(S) In azoospermic men with the Klinefelter syndrome, histopathologic findings seem to be predictive for successful sperm recovery. Infertility work-up, including diagnostic testicular sperm recovery, is recommended, and, if possible, viable sperm should be cryopreserved.

Vaginal administration of the nitric oxide donor isosorbide mononitrate for cervical ripening at term: a randomized controlled study☆

OBJECTIVE Our aim was to examine the effect of the nitric oxide donor isosorbide mononitrate on the uterine cervix at term and to evaluate possible adverse effects of this treatment. STUDY DESIGN Term pregnant women were randomly selected to receive either 40 mg vaginally administered isosorbide mononitrate or placebo 4 hours before elective cesarean section. Cervical status, maternal blood pressure, maternal pulse rate, fetal heart rate, umbilical arterial Doppler indices, and various side effects were examined. RESULTS Isosorbide mononitrate induced a significant increase in cervical distensibility. It also caused a significant change in maternal blood pressure and maternal pulse rate. In addition, the frequency of maternal headache and palpitations was significantly higher in the isosorbide mononitrate group versus the placebo group. However, the intensity of these symptoms was moderate. CONCLUSION Vaginal administration of 40 mg of isosorbide mononitrate induces cervical ripening at term. Although the majority of women experienced side effects, no serious clinical maternal or fetal adverse effects, resulting in specific medication or emergency cesarean section, were diagnosed.

Sublingual nitroglycerin for management of retained placenta

The aim of the study was to investigate the effect of sublingual nitroglycerin for management of retained placenta and to assess possible adverse effects of the treatment.

Swedish Sperm Donors Are Driven by Altruism, but Shortage of Sperm Donors Leads to Reproductive Travelling

Background: Swedish legislation requires that sperm donors are identifiable to offspring. In Denmark sperm donors remain anonymous. The aim of this study was to examine sperm donation in Sweden by identifying socio-demographic backgrounds, motivations and attitudes among donors and to describe options and plans of sperm recipients. Furthermore, the willingness of Swedish health care providers to assist in treatment abroad, where sperm from an anonymous donor were to be used, was assessed. The extent of travelling to Denmark for reproductive purposes was also examined. Methods: Thirty Swedish sperm donors completed a questionnaire and were interviewed about their backgrounds, motivations and attitudes. Thirty couples where the infertility workup had shown azoospermia were interviewed about their options for achieving parenthood. The willingness to assist in fertility treatment abroad and the extent of reproductive cross border travelling were assessed by interviewing health care providers and by contacting Danish clinics. Results: Almost all donors were Caucasian. The main motivation for sperm donors was to help others. Owing to shortage of sperm donors many Caucasian recipients intended to have treatment abroad. For most non-Caucasian recipients sperm from a donor of appropriate ethnicity were not available in Sweden. Whether the sperm donor was anonymous or identifiable was not of major importance to most sperm recipients. Health care providers expressed unanimous willingness to assist in treatment with sperm from an anonymous donor. Our inquiry indicated that more than 250 Swedish sperm recipients travel to Denmark annually. Conclusions: Identifiable sperm donors are driven by altruistic motives, but shortage of sperm donors leads to reproductive travelling. Recruitment strategies to increase the number of sperm donors in Sweden are therefore warranted.

Nitric oxide–mediated effects on myometrial contractility at term during prelabor and labor

OBJECTIVE To assess the existence of a nitric oxide (NO) system in the human myometrium and the effects of mediators of this system on contractile activity in vitro. METHODS Myometrial tissue was obtained before the onset of labor and during labor at term. Production of NO was assessed by the use of nicotinamide dinucleotide phosphate diaphorase staining and by immunoblots for NO. Effects of NO were examined by adding L-arginine (the substrate for NO synthesis); N(G)-nitro-L-arginine methyl ester (an inhibitor of NO synthase); two NO donors, sodium nitroprusside and spermine NONOate; as well as 8-bromo cyclic guanosine monophosphate (8-bromo cGMP) (a second messenger analogue) to organ baths. RESULTS Myometrial NO production was indicated by positive nicotinamide adenine dinucleotide phosphate diaphorase staining. Immunoblots detected endothelial NO synthase, whereas only a weak signal for inducible NO synthase was seen. The addition of L-arginine (10(-4)-10(-3) mol/L) did not result in any change of contractility. N(G)-nitro-L-arginine methyl ester (10(-3) mol/L) caused a minor increase of contractility in half of the specimens. Sodium nitroprusside, spermine NONOate, and 8-bromo cGMP resulted in a concentration-dependent inhibition of contractility (10(-7)-10(-6) mol/L for sodium nitroprusside, 10(-6)-10(-5) mol/L for spermine NONOate, and 10(-5)-10(-3) mol/L for 8-bromo cGMP). However, at 10(-5)-10(-4) mol/L, sodium nitroprusside exhibited a dose-dependent increase in the frequency of contractions. Women in prelabor did not differ from those in active labor. CONCLUSION The myometrium produces NO at term. Nitric oxide inhibits myometrial contractile activity. The responsiveness to NO is similar in nonlaboring and laboring women.

Testicular Sonography in Men with Klinefelter Syndrome Shows Irregular Echogenicity and Blood Flow of High Resistance

AbstractPurpose: Klinefelter syndrome is the most common chromosomal aberration among azoospermic men. We wanted to compare testicular echogenicity and intratesticular arterial blood in men with this syndrome versus men with normal sperm parameters. Methods: Testicular sonography including Doppler imaging, was performed as part of the infertility workup in 26 men with Klinefelter syndrome as well as in 26 men with normal sperm parameters. Results: In men with Klinefelter syndrome, sonography of the testicular parenchyma revealed a heterogenous irregular pattern with spread hyper- and hypoechoic foci. Doppler sonography resulted in waveforms of high impedance patterns, reflecting intratesticular blood flow of a high resistance. In men with normal sperm parameters testicular echogenicity was of an almost homogenous regular pattern. In these men, intratesticular blood flow typically exhibited a pattern of low vascular resistance. Conclusions: The study demonstrates that testicular echogenicity as well as intratesticular blood flow are different in men with Klinefelter syndrome versus men with normal sperm parameters.

Pregnancies following ultrasound-guided drainage of tubo-ovarian abscess

OBJECTIVE To study fertility among women treated by means of ultrasound-guided drainage and antibiotics for tubo-ovarian abscess (TOA). DESIGN Retrospective cohort study. SETTING A tertiary referral center. PATIENT(S) One hundred women of reproductive age treated for TOA between June 1986 and July 2003. INTERVENTION(S) Transvaginal ultrasound-guided drainage of TOA was performed in all patients. The procedure was repeated if a substantial amount of pus was seen using ultrasonography 2-5 days after the initial aspiration, and repeated later if necessary. MAIN OUTCOME MEASURE(S) Frequency of naturally conceived pregnancies. RESULT(S) Twenty of 38 (52.6%; 95% CI 36.5-68.9%) women who intended to have a child achieved pregnancy naturally and became mothers. In addition, 7 (50%) of 14 women who were not on birth control on a regular basis became pregnant. No ectopic pregnancies were registered. CONCLUSION(S) Ultrasound-guided drainage of TOA in combination with antibiotics seems to preserve fertility in approximately half of the patients.

Outpatient cervical ripening before first‐trimester surgical abortion: a comparison between misoprostol and isosorbide mononitrate

Background. Vaginal administration of prostaglandin analogues as well as nitric oxide donors before first‐trimester surgical abortion has been shown to induce effective cervical ripening. In addition, nitric oxide donors, such as isosorbide mononitrate and nitroglycerin, have been associated with a patient‐friendly side‐effect profile when administered 3 h before the surgical procedure. We wanted to compare the cervical ripening effect and possible side effects of isosorbide mononitrate and the prostaglandin analogue misoprostol when self‐administered at bedtime the evening before surgical abortion. Methods. One hundred and twenty nulliparous women scheduled for suction termination of pregnancy in the first trimester were randomly assigned to receive per vaginam either 40 mg of isosorbide mononitrate or 200 µg of misoprostol. Sixty of the women were included for assessment of cervical ripening as well as evaluation of side effects. The other 60 women were recruited for assessment of side effects only. Cervical ripening was evaluated by measuring baseline cervical dilation and the cumulative force to dilate the cervix to 9 mm by means of a cervical tonometer. For assessment of side effects, the women were asked to complete a symptom questionnaire. Results. Cervical resistance was significantly higher in women treated with isosorbide mononitrate compared to misoprostol (median cumulative force 73 versus 15 N). Common side effects of misoprostol were abdominal pain (69%), nausea (44%), and vaginal bleeding (66%), while in the isosorbide mononitrate group headache was frequently experienced (79%). In both treatment groups, the frequency and intensity of side effects gradually increased during the treatment interval. Conclusions. Misoprostol induced a more pronounced cervical ripening than isosorbide mononitrate, but both regimens were associated with a high frequency of side effects.

Nitroglycerin for Management of Retained Placenta: A Multicenter Study

The primary aim was to determine if sequential administration of oxytocin and nitroglycerin is effective for management of retained placenta when performed by obstetricians with no experience of the method. Secondary aims were to examine possible adverse effects of nitroglycerin. One hundred and five women with retained placenta were randomly selected to receive either 1 mg nitroglycerin or placebo tablets sublingually if intravenous oxytocin had failed to expel the placenta. At two of the hospitals some of the midwives were familiar with the use of nitroglycerin. The other midwives and all the participating obstetricians had no clinical experience of the method. In the treatment group, detachment of placenta following nitroglycerin occurred in 37.3% of the women compared to 20.4% in the placebo group (P = 0.056). In the two hospitals with some experience of the method, placenta was removed in 9 of 19 (47.4%) women in the nitroglycerin group compared to 3 of 17 (15.0%) women in the placebo group. No adverse effects of clinical importance were registered. Although the difference between the two groups did not reach statistical significance, the higher success rate in the two hospitals with some experience could indicate that clinical experience is of importance in order to achieve placental detachment.