Francois X. Aubriot

Myomectomy by laparoscopy: a preliminary report of 43 cases

OBJECTIVE To evaluate the technique and short-term results of intraperitoneal (IP) myomectomies. DESIGN From January 1, 1990, to March 1, 1991, IP myomectomies were performed in all cases in which it appeared feasible. SETTING This study was conducted in a tertiary care center, the Port-Royal University Hospital. PATIENTS, PARTICIPANTS Among 49 consecutive patients with interstitial or subserous myomas, 6 patients with voluminous, multiple myomas had laparotomies. Intraperitoneal myomectomy was performed in 43 patients. The indication for laparoscopy was a pelvic mass in 29 cases, infertility in 13, and severe endometriosis in 1 case. INTERVENTIONS Thermocoagulation or monopolar coagulation was used for the uterine incision. Myometrium and serosa were sutured in 23 of 43 patients. Myomas were removed through the suprapubic puncture site after fragmentation of large myomas. MAIN OUTCOME MEASURE(S) We evaluated the length of the procedures, blood loss, and postoperative course. RESULTS Ninety-two myomas were removed laparoscopically. No complication was observed. CONCLUSIONS In selected cases, IP myomectomy appears to be a safe technique with the advantages of laparoscopic surgery.

Laparoscopic salpingectomy for tubal pregnancy

This study presents 100 consecutive cases of total salpingectomy by laparoscopy for the treatment of ampullar ectopic pregnancy. A three-puncture technique was used, and the salpingectomy was done by thermocoagulation and transection of the isthmus, mesosalpinx, and tubo-ovarian ligament. Tubal extraction was accomplished by one of the suprapubic punctures with the use of a polyp forceps. No complications have been encountered during the operation. However, because of severe pelvic adhesions or a voluminous hematocele, laparotomy was used in two cases (2%). The only postoperative complication was a deep vein thrombosis in one of the patients. A second-look operation was performed in 36 cases, and good healing with no adhesion formation at or near the site of salpingectomy was found. This technique therefore appears to be simple, fast, and almost complication-free.

Reproductive outcome after laparoscopic salpingectomy for tubal pregnancy

Since 1983, we have performed laparoscopic salpingectomy as a routine procedure for ectopic pregnancy (EP) in cases where conservative management is impossible or contraindicated. The main indications are a ruptured tubal gestation, a pathological tube, a history of tuboplasty, and an ipsilateral recurrence. This technique is simple, quick, and safe. Reproductive outcome after laparoscopic total salpingectomy for EP was evaluated in 125 cases between January 1983 and December 1987. The pregnancy rate was 33.6%. In our population, there was a high proportion of patients with a pathological or absent contralateral tube (74.4%). In patients with a normal contralateral tube (32 cases), the live birth rate (46.9%) was greater but not significantly than in patients (39 cases) with a patent but pathological tube (25.6%). In vitro fertilization (IVF) was performed in 59 patients; clinical pregnancy was obtained in 40.7% of cases. These encouraging results lead us rapidly to consider IVF in patients with a pathological contralateral tube.

Terminal tuboplasties by laparoscopy : 65 consecutive cases

A series of 65 consecutive laparoscopic distal tuboplasties, performed from May 1986 to May 1988 is reported. Thirty-one were fimbrioplasties and 34 were neosalpingostomies. Outcome was evaluated at 18 months postoperatively. Twenty-two patients obtained pregnancies (33.8%), of which 18 were intrauterine (27.7%). The intrauterine pregnancy rate was 25.8% after fimbrioplasty and 29.4% after neosalpingostomy. These results are comparable with those obtained after microsurgery. Progress in operative laparoscopy may be attributed to the development of an appropriate atraumatic instrumentation and the CO 2 laser. The major advantage of laparoscopic techniques is their availability at the time of diagnostic laparoscopy. Immediate opening of hydrosalpinges allows for precise evaluation of the tubal mucosa, thereby establishing prognosis. In cases with a severely altered mucosa, in vitro fertilization may be considered immediately. When the mucosa is satisfactory, laparoscopic fimbrioplasty or neosalpingostomy may be performed. Within 1 year after one of these procedures, a pregnancy is generally achieved in 1 of 3 patients.

A new in vitro fertilization technique: intravaginal culture.

Intravaginal culture (IVC) is a new technique elaborated by the authors for the fertilization and culture of human oocytes. Its principle consists of fertilization and early development of the eggs in a closed, air-free milieu without the addition of CO2. One to five ovocytes are deposited in a tube completely filled with 3 ml of culture medium less than 1 hour after their recovery, with 10,000 to 20,000 spermatozoa per ml previously prepared. The tube is then hermetically closed and it is placed in the maternal vagina and held by a diaphragm for incubation for 44 to 50 hours. After this time, the content of the tube is examined and embryos are transferred to the uterus. In the first 100 consecutive punctures, 22 clinical pregnancies were obtained: 17 deliveries, 3 spontaneous abortions, and 2 tubal pregnancies. Also, a randomized study comparing IVC to in vitro fertilization (IVF) was done (160 cycles) and no statistically different cleavage, transfer, or pregnancy rate was seen between IVC and IVF. By simplifying the laboratory manipulations, this technique decreases the cost of IVF and permits its standardization and diffusion. It creates a psychologic comfort permitting active participation of the mother in this stage of embryo development. Also, the use of this technique may give greater knowledge of human gamete metabolism and of the physiology of reproduction.

Tubal causes of ectopic pregnancy

141 patients with tubal pregnancies underwent complete salpingectomy in the department of obstetrics and gynecology at Port Royal, Paris between January 1, 1977-January 31, 1984. Usually, a tubal pregnancy occurs in the affected tube. Ampullary pregnancy (88%) is the result, in 95% of the cases, of ampullary pathology. Isthmic pregnancy (12%) is probably due, in every case, to a pathology of the isthmus which is generally associated with ampullary disease. In these cases, too, chronic salpingitis is usually the reason while endometriosis is very rare. The high rate of reoccurrence after conservative surgery results from the high rate of initial tubal alterations. (authors modified)

Human egg fertilization in capillary tubes

1. Vatev, I: In vitro fertilization of human ova. Obstet Gynecol (Sofia) 1978;1:68-73 2. Vatev, I, Vassilev, B, Zhivkov, S: Incipient interactions of human gametes in vitro. Compt Rend Acad Bulg Sci 1983;36:1235-1238 3. Vatev, I: Testing of a human in vitro fertilization system by the culture and transfer of mouse embryos. In Abstracts of 4th Symposium on Biotechnology, Varna, (Bulgaria), 1986, p. 182 4. Vatev, I: High fertilization rate in a procedure for in vitro fertilization of human oocytes upon using a chemically defined medium. Compt Rend Acad Bulg Sci 1987:40:101-104

Endométriose et infertilité

L’endometriose est une maladie gynecologique frequente dont la prevalence dans la population generale est estimee entre 6 et 10% (1). Elle atteint des femmes en âge de procreer. De nombreuses etudes ont montre que l’endometriose etait responsable d’infertilite mais les facteurs causant l’infertilite en cas d’endometriose restent mal etablis. Ceci est du pour une part a la grande diversite de l’endometriose et au fait que sa physiopathologie reste mal elucidee.

Lessons Learned from IVC (Intra-Vaginal Culture)

In vitro fertilization (IVF) represents a major technological advancement in fertility treatment. The steps include ovulation induction, oocyte retrieval, sperm preparation, fertilization and embryo transfer. In an attempt to simplify the fertilization process, we developed the intravaginal culture (IVC) at the Port Royal University Clinic in 1985.