Gabriel Oelsner

Laparoscopy versus laparotomy in the management of adnexal masses during pregnancy

OBJECTIVE To compare the outcome of pregnancy after operative laparoscopy or laparotomy for the management of adnexal pathology during pregnancy. DESIGN Retrospective comparative study. SETTING University tertiary care referral center for endoscopic surgery. PATIENT(S) Eighty-eight pregnant women who underwent 93 operations for suspected adnexal pathology at our institute. Laparoscopy was performed during the first trimester in 39 patients. The remaining 54 patients underwent laparotomy, 25 during the first trimester and 29 during the second trimester. INTERVENTION(S) Laparoscopy or laparotomy for the management of adnexal masses during pregnancy. MAIN OUTCOME MEASURE(S) Operative and postoperative maternal complications, miscarriage, congenital malformations, and newborn long-term outcome. RESULT(S) No operative or postoperative maternal complications occurred in the pregnant women who underwent laparoscopic surgery. In this group of 39 women, 5 women had a first-trimester miscarriage and 2 newborns had congenital malformations (hypospadias and cleft lip and palate). Two miscarriages occurred in the first-trimester laparotomy group, and 1 congenital malformation (transposition of the great vessels) was diagnosed in the second-trimester laparotomy group. CONCLUSION(S) Laparoscopic gynecologic surgery appears to be safe during pregnancy, although prospective controlled studies and national registries encompassing larger numbers of cases are needed.

The Study of Induction of Ovulation with Menotropins: Analysis of Results of 1897 Treatment Cycles *

Ovulation and the development of a corpus luteum with intact endocrine function is the result of a perfectly balanced interaction among hypothalamic gonadotropin-releasing hormone, pituitary gonadotropins, and ovarian response. Any disturbance in one of these endocrine glands or in the complex feedback mechanism of the closed circuit would result in anovulation. The use of menotropins is appropriate for patients lacking endogenous gonadotropins or for patients having ovaries capable of a normal response but in whom drugs capable of inducing gonadotropin secretion have failed to induce ovulation. This report is based upon computer tabulations of pooled data abstracted from 510 patients to whom 1897 treatment cycles with menotropins were administered during the last 15years. The results of treatment are based upon detailed analyses in different groups of patients to whom the same gonadotropin preparation was administered according to a similar treatment schedule. The percentage of patients who conceived following therapy (the pregnancy rate) in group I (women with negligible endogenous estrogen activity and low gonadotropin levels) was 60.4%; in group II (women with normal gonadotropin levels and distinct endogenous estrogen activity in whom all other treatments had failed) the pregnancy rate was 21.4%. The success rates (the percentages of women who took home at least one living child) were 52.1% in group I and 14.5% in group II. Altogether, 250 children were born to 184 women who conceived following treatment. The mean numbers of treatment cycles per patient were 3.69 in group I and 3.24 in group II. Among women of group I who conceived, 94.1% did so within four treatment cycles and of group II patients 95.2% did so within six treatment cycles. The over-all mild hyperstimulation rate was 4.26% and the severe hyperstimulation rate was 0.36%. The over-all multiple pregnancy rate was 32.5%.

Pregnancy Outcome after Laparoscopy or Laparotomy in Pregnancy

STUDY OBJECTIVE To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS Three hundred eighty-nine pregnant women. INTERVENTION Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Laparoscopic detorsion allows sparing of the twisted ischemic adnexa.

STUDY OBJECTIVE To determine the safety and outcome of laparoscopic detorsion in the management of the twisted ischemic, hemorrhagic adnexa. DESIGN Retrospective chart review and prospective follow-up (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Fifty-eight women with twisted black-bluish ischemic adnexa encountered at laparoscopy. INTERVENTION Laparoscopic detorsion with adnexal sparing. MEASUREMENTS AND MAIN RESULTS All patients had a benign immediate postoperative course. Transient temperature elevation occurred in seven women (12.1%). No signs of pelvic or systemic thromboembolism were detected in any patient. Long-term follow-up included transvaginal ultrasound, which revealed follicular development in the previously twisted adnexa in 54 women; normal macroscopic appearance at incidental subsequent surgery in 9; and in vitro fertilization with retrieval of oocytes from the previously twisted side in 4. CONCLUSION Laparoscopic detorsion of the twisted ischemic, hemorrhagic adnexa is a safe procedure with minimal postoperative morbidity and a potential for the ovary to recuperate fully with preservation of normal function. Laparoscopic adnexa-sparing procedures should be performed in place of traditional salpingo-oophorectomy in women with this disorder who desire future fertility. (J Am Assoc Gynecol Laparosc 6(2):139-143, 1999)

Retrograde Ejaculation: Pathophysiologic Aspects and Report of two Successfully Treated Cases *

The ejaculatory process consists of two stages. During the first stage the semen is pumped into the posterior urethra and during the second stage the semen is propelled via the urethra through the external meatus. A pathologic second stage may lead to retrograde ejaculation of the semen into the urinary bladder. Attempts to achieve fertility in such patients can be made in two ways; namely through procedures to restore antegrade ejaculation (mainly using alpha-sympathomimetic agents) and procedures to regain viable and fertile sperm from the urinary bladder after sexual intercourse, with subsequent artificial insemination. The latter way of treatment was used in two patients who were referred for infertility and in whom retrograde ejaculation had been diagnosed. Postcoital urinary specimens were obtained by micturition and centrifuged. In one patient the sediment was washed with a nutrient solution; the other patient received alkalizing agents prior to intercourse in order to neutralize the urinary pH. The wives were inseminated on appropriate days and conceived. Both delivered healthy babies after uneventful pregnancies.

Diagnosis and treatment of heterotopic pregnancy compared with ectopic pregnancy.

STUDY OBJECTIVE To compare the diagnosis and management of ectopic (EP) and heterotopic pregnancies (HP). DESIGN Retrospective comparative study (Canadian Task Force classification II-2). SETTING University tertiary referral center for endoscopic surgery. PATIENTS Twelve women with HP and 210 women with laparoscopically confirmed EP. INTERVENTION Laparoscopic treatment. MEASUREMENTS AND MAIN RESULTS Among the 12 women with HP, all but 1 had received ovulation induction, 10 underwent in vitro fertilization-embryo transfer, and 1 conceived with clomiphen citrate. In the EP group 33 patients (15.7%) conceived spontaneously (p <0.05). Six women (50%) with HP had had previous pelvic surgery and three had a history of EP and salpingectomy. Four patients (33.4%) with HP and 29 (13.8%) with EP suffered from hypovolemic shock and required blood transfusion (p <0.05). Three of these four women with HP experienced physician and patient delays before admission. The sonographic diagnosis was correct in all women with HP and in 94.3% of women with EP. The median gestational age at diagnosis was 7.5 and 7.2 weeks for HP and EP, respectively. Six (50%) women with HP had evidence of fetal pulse in the ectopic gestation compared with 17 (8.1%) with EP (p <0.05). In addition, 66.7% and 24.7%, respectively, had ruptured tube (p <0.05). Mean +/- SD hemoperitoneum was 833.4 +/- 777 and 305 +/- 121 ml, respectively (p <0.05). Conversion to laparotomy was required in one (8.3%) and eight (3.8%) women, respectively (p <0.05). No major operative or postoperative maternal complications occurred in either group. Two women with HP had miscarriages, two have a continuing pregnancy, and eight delivered healthy newborns. CONCLUSION Women with HP are at significantly greater risk for hypovolemic shock and requiring blood transfusion than those with EP. The diagnosis of EP in cases of HP is difficult due to the presence of an intrauterine gestational sac and hyperstimulated ovaries. A greater level of suspicion may allow early laparoscopic intervention before life-threatening intraabdominal bleeding has occurred.

Operative laparoscopy for management of ectopic pregnancy in patients with hypovolemic shock.

STUDY OBJECTIVE To determine the safety of operative laparoscopy in the management of ectopic pregnancy in women with hypovolemic shock. DESIGN Retrospective chart review. SETTING University-affiliated hospital. PATIENTS Two hundred eleven women with tubal pregnancy, of whom 33 were suffering from hypovolemic shock, based on a combination of signs and symptoms including hypotension, tachycardia, anxiety, thirst, tachypnea, and slow capillary refill. INTERVENTION Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS Mean +/- SEM intraabdominal blood loss was significantly (p <0.01) higher in women with hypovolemic shock, 1369 +/- 149 versus 114 +/- 14 ml. Blood transfusions were given to 88% and 0.5%, respectively (p <0. 01). Laparoscopic salpingectomy was performed in all hemodynamically compromised women compared with 87% of stable women. Conversion to laparotomy was required in three patients in the hypovolemic shock group and five in the stable group. All patients had an uncomplicated postoperative course and made a full recovery. CONCLUSION The availability of optimal anesthesia and advanced cardiovascular monitoring, and the ability to convert rapidly to laparotomy if required, allow safe performance of operative laparoscopic surgery in most women in hypovolemic shock. In fact, the superior exposure of laparoscopy, providing rapid diagnosis and control of the source of bleeding, makes it a highly suitable approach.

Treatment of interstitial pregnancy with methotrexate via hysteroscopy

We present a case in which treatment of interstitial pregnancy with local MTX administration was performed successfully through hysteroscopic vision, without the need to operate. Decreased gestational sac dimension and increased or low beta-hCG level ( < 1,400 mIU/mL) facilitates the success rate. The follow-up showed disappearance of the gestational sac and decrease of beta-hCG levels to < 10 mIU/mL. We conclude that local MTX administration via hysteroscopy after tubal ostium visualization is feasible. The procedure should be considered in women during the reproductive age, especially in rare cases of interstitial pregnancy.

Spontaneous pregnancy and its outcome after human menopausal gonadotropin/human chorionic gonadotropin-induced pregnancy.

The fertility in previously sterile women who conceived at least once following hMG/hCG-induced ovulation is investigated. The study comprises 141 women. The cumulative spontaneous pregnancy rate (CSPR) was calculated using life table analysis and was found to be 30.4% after 5 years. The CSPR for subsequent pregnancies reached 91.3% after 5 years. This figure is similar to that of normal parous women, although the study group (previously infertile women) requires a larger exposure period to attain the figure. The spontaneous abortion rate in the hMG/hCG-induced pregnancies was 29%; whereas in subsequent spontaneous pregnancies this rate was 8.8%. This difference in rate was found to be statistically significant, and the possible reasons are discussed.

A new approach for the treatment of interstitial pregnancy

The surgical treatment of interstitial pregnancy consists of either cornual resection or hysterectomy, which may seriously impair future fertility. We report a new approach that avoids surgical intervention. This presents a major breakthrough in the management of interstitial pregnancy.