Ertan Saridogan

Uterine artery embolization for fibroids is associated with an increased risk of miscarriage

OBJECTIVE To investigate how uterine artery embolization (UAE) might alter the risk profile for pregnancies complicated by fibroids. DESIGN Systematic literature review and meta-analysis of existing studies. SETTING Academic reproductive medicine unit. PATIENT(S) Women with fibroids. INTERVENTION(S) A systematic literature review, raw data extraction, and data analysis. MAIN OUTCOME MEASURE(S) Rates of miscarriage, preterm delivery, malpresentation, intrauterine growth restriction (IUGR), cesarean delivery, and postpartum hemorrhage (PPH). RESULT(S) Two hundred twenty-seven completed pregnancies after UAE were identified. Miscarriage rates were higher in UAE pregnancies (35.2%) compared with fibroid-containing pregnancies matched for age and fibroid location (16.5%) (odds ratio [OR] 2.8; 95% confidence interval [CI] 2.0-3.8). The UAE pregnancies were more likely to be delivered by cesarean section (66% vs. 48.5%; OR 2.1; 95% CI 1.4-2.9) and to experience PPH (13.9% vs. 2.5%; OR 6.4; 95% CI 3.5-11.7). Rates of preterm delivery (14% vs. 16%; OR 0.9; 95% CI 0.5-1.5), IUGR (7.3% vs. 11.7%; OR 0.6; 95% CI 0.3-1.3), and malpresentation (10.4% vs. 13%; OR 0.8; 95% CI 0.4-1.5) were similar in UAE pregnancies and in control pregnancies with fibroids. CONCLUSION(S) The risk of miscarriage seems to be increased after UAE. In contrast, apart from an increased risk of abdominal delivery and PPH, critical adverse obstetric sequelae of IUGR and prematurity appear no more likely after UAE.

Anti-Mullerian hormone is increased in follicular fluid from unstimulated ovaries in women with polycystic ovary syndrome

BACKGROUND Anti-Mullerian hormone (AMH) may have a role in disordered folliculogenesis in polycystic ovary syndrome (PCOS). Though there have been several investigations into circulating AMH levels in patients with PCOS, no previous studies have compared AMH concentrations in the follicular fluid of unstimulated ovaries in women with PCOS with that of normally ovulating women. METHODS Follicular fluid was aspirated from 4-8-mm follicles of unstimulated ovaries during routine laparoscopy or laparotomy from women with anovulatory PCOS (n = 11) and those with regular ovulatory cycles (n = 8). Follicular AMH was compared in the two groups. Serum samples were analysed for AMH and endocrine profile. RESULTS Follicular fluid AMH levels were significantly higher (P < 0.0001) in women with anovulatory PCOS (median: 466.2 ng/ml) compared with normal-ovulatory controls (median: 78.0 ng/ml). Mean follicular fluid AMH levels in PCOS patients were 60 times higher than in the serum. Moreover, there was a significant correlation between the follicular fluid and serum concentrations of AMH in the PCOS group (r = 0.86; P = 0.007) but not in controls. CONCLUSIONS Highly elevated AMH in follicular fluid from PCOS patients in contrast to age-matched normal controls suggests that increased circulating concentrations of AMH are partly due to the increased production of AMH by individual follicles and not simply attributable to the increased number of small antral follicles. This suggests an intrinsic abnormality in the ovarian follicles themselves in PCOS, which could contribute to disordered folliculogenesis.

Importance of sperm-to-epithelial cell contact for the capacitation of human spermatozoa in fallopian tube epithelial cell cocultures

OBJECTIVE To investigate the mechanisms involved in the stimulatory effect of fallopian tube epithelial cell coculture on sperm movement characteristics. DESIGN Human spermatozoa were cultured with human fallopian tube epithelial cell monolayers. A microporous membrane was used to prevent sperm-to-epithelial cell contact. Sperm movement characteristics were measured at 4 and 24 hours. SETTING University hospital and fertility center. PATIENT(S) Voluntary donors. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Movement characteristics of human spermatozoa. RESULT(S) Fallopian tube epithelial cell coculture increased sperm motility, curvilinear velocity, amplitude of lateral head displacement, and hyperactivated motility, mainly at 24 hours, compared with controls. These stimulatory effects were inhibited when a microporous membrane prevented cell-to-cell contact between sperm and fallopian tube epithelial cells. CONCLUSION(S) Physical contact between sperm and epithelial cells in coculture systems seems to be the main factor in stimulating sperm movement characteristics, and this could be the main mechanism of in vivo sperm capacitation.

Angiotensin II stimulates sperm motility

The physiological factors which induce and maintain mammalian sperm maturation and motility generally remain unclear, although several agents are known to be involved. We recently described the application of immunocytochemical and immunoblotting methods to identify the angiotensin II type 1 (AT1) receptor in the tails of ejaculated rat and human sperm, and gave evidence to show that angiotensin II may promote sperm motility. These data are extended here by the application of a computerised sperm tracking system (the Hobson Sperm Tracker) to demonstrate that AII has actions on specific motility parameters, including curvilinear velocity, straight line velocity, and amplitude of lateral head movement. Since local tissue renin-angiotensin systems are present in both male and female tracts, the data suggest that angiotensin II has a role in the maintenance of sperm function and fertility.

Role of utero–ovarian vascular impedance: predictor of ongoing pregnancy in an IVF–embryo transfer programme

The objective of this study was to evaluate the role of uterine, endometrial and follicular blood flow in prediction of ongoing pregnancy after assisted conception. A prospective observational study was conducted on 53 women undergoing IVF treatment. Transvaginal colour and pulsed Doppler measurements were performed on the day that pituitary suppression was confirmed, on day 10 of ovarian stimulation and on the day prior to human chorionic gonadotrophin injection. On the last day of ovarian stimulation, blood flow in the ascending uterine artery of the women who would conceive was characterized by significantly lower pulsatility index values. Sub-endometrial vascular impedance was comparable in the pregnant and non-pregnant groups. There were no differences in the perifollicular vascularity between pregnant and non-pregnant women. The chance of achieving pregnancy predicted by uterine artery Doppler and perifollicular blood flow in women whose PI values were higher than 3.26 and 1.08 was very low, with a sensitivity of 1.00 and specificity of 0.59 and 0.82 respectively. The data provide evidence for an association between utero-ovarian perfusion and reproductive outcome following IVF treatment. Uterine and ovarian vascular impedance values identify those women whose pregnancy chances are significantly limited. Measures to decrease vascular impedance in such women might enhance pregnancy rates by improving embryo quality and uterine receptivity for implantation.

See-and-treat outpatient hysteroscopy: an analysis of 1109 examinations.

The aim of this study was to assess the feasibility of diagnostic and therapeutic outpatient hysteroscopy. Data were collected prospectively from 1109 consecutive hysteroscopy examinations. The main outcome measure was success and failure of diagnostic and therapeutic outpatient hysteroscopy examination. The mean age (sd) was 47.7 (11.8) years and 53.3% and 39.5% of subjects were post-menopausal and nulliparous, respectively. The most common indications for referral were post-menopausal bleeding (39.8%), menorrhagia (25.7%) and irregular periods (14.5%). Hysteroscopy examination was successfully completed in 96.2% (1067/1109) of the subjects. Success was negatively influenced by age and menopausal status but not parity, although the differences between the age groups and pre- versus post-menopausal groups were minimal. The most common abnormalities were intrauterine polyps (425/1109, 38.3%) and submucous fibroids (142/1109, 12.8%). Of these two groups, respectively, 285/425 (67.1%) and 23/142 (16.2%) subjects had complete polyp and fibroid resection in the outpatient setting and 116/425 (27.3%) and 63/142 (44.4%) underwent polyp and fibroid resection under general anaesthesia. In conclusion, diagnostic and therapeutic hysteroscopy is feasible and highly successful in an outpatient setting. The majority of subjects with endometrial polyps and intrauterine adhesions are amenable to a see-and-treat approach.

Screening for Down's syndrome: experience in an inner city health district

Objective To review the experience of Downs syndrome screening in an inner city health district.

Is naso-gastric tube insertion necessary to reduce the risk of gastric injury at subcostal laparoscopic insufflation? A pilot study.

Background and objective: Midlatency auditory‐evoked potentials, as measures of the anaesthetic state, were evaluated at similar levels of bispectral index in cardiac surgical patients maintained with either propofol or isoflurane anaesthesia. Methods: Twenty‐four patients were randomly allocated to anaesthesia with propofol (n = 12) or isoflurane (n = 12). Bispectral index was maintained below 60 during surgery. Auditory‐evoked potentials were collected before induction of anaesthesia, 10 min after intubation, 30 min after sternotomy, during cardiopulmonary bypass at the time of cross‐clamping of the aorta and during stable mild hypothermia, after de‐clamping of the aorta, and after the operation. Results: At the pre‐determined time points, bispectral index values showed comparable depth of hypnosis in both groups. The latency of the Nb component of midlatency auditory‐evoked potentials was significantly increased in the isoflurane group after intubation (P < 0.001) and that of both the Nb and the Pa components after sternotomy (P < 0.001) compared with the propofol group. No differences between the groups were detected with respect to haemodynamic variables. No patient reported recall of intraoperative events. Conclusion: After intubation and surgical stimulation, when bispectral index was at a constant level, there was a difference in the Nb and Pa components of the midlatency auditory‐evoked potentials between the two anaesthetic regimens, indicating a distinction in the state of anaesthesia. Our results suggest that the parallel use of these two electrophysiological methods can show differences in the components of anaesthesia between various anaesthesia methods in cardiac surgical patients.EDITOR: The standard entry point for abdominal insufflation and primary port site placement in gynaecological laparoscopy is the umbilicus. However, where there has been previous abdominal surgery, which increases the risk of bowel adhesions beneath the umbilicus, the use of Palmer’s point (the left subcostal area in the mid-clavicular line) has been advocated [1]. The principal risks associated with this entry technique are damage to the stomach or spleen. Facemask ventilation with positive pressure prior to intubation is a necessary part of anaesthesia, but it is known to insufflate the stomach, and even more so than other forms of ventilation [2]. The purpose of this study was to determine whether the insertion of a naso-gastric tube would reduce the degree of gastric distension and, hence, reduce the potential risk of gastric injury during subcostal insertion of a Veress needle and the primary port. This was a single blinded randomized controlled trial, approved by the local Ethics Committee at the University College London Hospitals’ Foundation Trust. Between June 2005 and March 2006, 42 patients were recruited. Patients were allocated randomly into those who were to receive a nasogastric tube (NGT Group) and those who were not to have one (no NGT Group). The chosen population consisted of females, ASA Grades I and II, aged 18 and above, undergoing elective gynaecological surgery with planned umbilical port incision. Patients having planned naso-gastric tube or subcostal port insertion were excluded. After pre-assessment and consenting, anaesthetic induction was performed using intravenous fentanyl 1.5 mcg kg, propofol 3 mg kg and vecuronium 0.15 mg kg. The same anaesthetist, in all cases, ventilated the patient’s lungs for a period of 2 min using a facemask with 50% oxygen and nitrous oxide mixture and 1.5% isoflurane. After tracheal intubation, an assistant opened the randomization envelope. Only those patients assigned to the NGT Group had a naso-gastric tube passed with a laryngoscope and Magill’s forceps. Placement of the naso-gastric tube was confirmed by air insufflation and auscultation over the stomach. The naso-gastric tube was subsequently aspirated. Next, to blind the surgeon, the head of the patient was covered with a sheet before being transported to the operating theatre. Anaesthesia was maintained with the gas mixture as described above. At laparoscopy, the scope was pointed upwards in the abdomen, and the degree of stomach distension was assessed. The same surgeon (AC) made all the assessments. Gastric distension was graded according to a visual assessment scale, with a scale of ‘0’ indicating minimum distension and ‘3’ indicating maximum. Surgery proceeded as planned, and the naso-gastric tube was removed prior to emergence. Out of the 42 patients recruited in the study, two patients were excluded, one due to accidental extraperitoneal insufflation and the other due to inadvertent opening of the randomization envelope. Patients in both groups were matched for age, weight, ASA Grades and airway. The results are summarized in Table 1. An empty stomach (score ‘0’: no distension) was seen in 16 out of 20 patients in the NGT Group compared to 12 out of 20 in the no NGT Group (not significant). In addition, three patients were assessed as having a high risk of gastric injury (score ‘3’: severe distension) and all were in the no NGT Group. The prevalence of severe distension in both the groups was not significantly different. No adverse effects occurred

Optimum uterine filling pressure for outpatient diagnostic hysteroscopy: a double-blind, randomized controlled trial

This study designed a double-blind, randomized controlled trial to assess whether adequate visibility can be achieved with lower uterine filling pressures using normal saline for diagnostic outpatient hysteroscopy and whether patient discomfort can be reduced. A total of 234 patients were randomized to 40 mmHg (77 patients), 70 mmHg (78 patients) or 100 mmHg (79 patients) of uterine filling pressures. The primary outcome measure was the proportion of procedures where adequate visibility was achieved during diagnostic outpatient hysteroscopy. The secondary outcome was the level of pain experienced by the patient as assessed using a visual analogue scale. There was adequate visibility in 87.0% of cases in 40 mmHg group, 94.9% in 70 mmHg group and 97.5% in 100 mmHg group. Visibility was lower with 40 mmHg compared with 70 and 100 mmHg (P < 0.05). The mean pain score in each group was not significantly different. In conclusion, this study showed that there was a higher trend towards inadequate visibility with lower filling pressures. Pressures of 70 and 100 mmHg may be equivalent to each other but not to a pressure level of 40 mmHg. Pain scores do not differ significantly with the pressure options used.

Surgical treatment of fibroids in heavy menstrual bleeding.

Uterine fibroids can cause abnormal uterine bleeding and their removal is beneficial in the treatment of heavy menstrual bleeding associated with fibroids for women who would like to preserve their uterus and fertility. Endoscopic (hysteroscopic and laparoscopic) approaches are the preferred methods of fibroid removal when appropriate. In the presence of submucosal fibroids, hysteroscopic resection is a simple, safe and effective treatment for heavy menstrual bleeding and reduces the need for more major surgery, such as hysterectomy. When abdominal myomectomy is required, laparoscopic myomectomy is the preferred choice in selected cases due to its advantages over open myomectomy.