Haya Al-Fozan

Safety and risks of laparoscopy in pregnancy.

Purpose of review The purpose of this review is to evaluate the indications, and the safety and efficacy of operative laparoscopy in pregnancy with a particular attention to the pregnancy outcome. Recent findings Hemodynamics changes during laparoscopic surgery in pregnancy are similar to those observed in the nonpregnant state. The procedure appears to be safe and reduces hospital admissions and frequency of premature labor. The safest time to perform laparoscopic surgery in pregnancy is at the second trimester. However, it can be complicated by injury to the gravid uterus and pregnancy loss. This is illustrated by a recent report of accidental gas insufflation into the amniotic cavity leading to the fetal loss. Summary The most common indications of laparoscopy in pregnancy are cholelithiasis, appendicitis, persistent ovarian cyst and adnexal torsion. In general, it is associated with a good maternal and fetal outcome. The occurrence of a miscarriage, premature labor or fetal death appears to be related to the underlying pathology, independent of the operative intervention. Due to the displacement of the appendix by the gravid uterus and the physiologic elevation of white blood cell count in pregnancy, diagnosis of appendicitis in pregnancy can be delayed with its sequelle. In one report, the incidence of fetal loss is 1.5% in uncomplicated appendicitis and 35% in the presence of ruptured appendicitis. Similarly, the fetal loss rate in uncomplicated cholecystectomy is 4%, but the fetal mortality in gallstone pacreatitis could be up to 60%. Laparoscopy in pregnancy should be performed with utmost care. In the second trimester of pregnancy, open laparoscopic approach is strongly recommended.

Left lateral predisposition of endometriosis and endometrioma

OBJECTIVE: To evaluate lateral distribution of endometriosis and ovarian endometrioma in women with endometriosis. METHODS: We evaluated operative reports of women who underwent laparoscopic treatment of endometriosis (n = 330) and ovarian endometrioma (n = 185) from January 1996 to January 2002. Data on all operative findings consisted of a written report, a diagram, the revised American Fertility Society classification of endometriosis, and a printout of the dictated report. RESULTS: Endometriotic implants were confined to one side of the pelvis in 143 women and bilaterally in 187 others. Endometriosis was significantly more frequent in the left (64.3%) than in the right hemipelvis (P < .001, odds ratio 3.3, 95% confidence interval 2.0, 5.3). Of those with bilateral lesions, adhesions were also more frequently found on the left than on the right hemipelvis (16.6% versus 6.9%, P < .01, odds ratio 2.6, 95% confidence interval 1.3, 5.2). Endometrioma was found in the left ovary (n = 90), in the right ovary (n = 59), and bilaterally (n = 36). Left ovarian endometrioma was found more frequently (60.4%) than right endometrioma (P < .001, odds ratio 2.3, 95% confidence interval 1.5, 3.7). This trend was not related to the size of the endometrioma. CONCLUSION: Our results confirm a left lateral predisposition of endometriosis and ovarian endometrioma. It is possible that this is related to decreased fluid movement in the left side of the pelvis because of the presence of sigmoid colon. These findings may support the theory that the origin of endometriosis is from the regurgitated endometrial cells. (Obstet Gynecol 2003;101:164‐6.

A Randomized Trial of Sublingual Misoprostol for Cervical Priming before Hysteroscopy

STUDY OBJECTIVE To evaluate the effects of sublingual misoprostol on cervical dilatation before hysteroscopy. DESIGN Prospective randomized study (Canadian Task Force classification I). SETTING University teaching center. PATIENTS Forty nulliparous women who received injection of leuprolide acetate 4 weeks before hysteroscopy, of whom 20 were randomized to treatment with misoprostol and 20 to placebo. INTERVENTION Sublingual misoprostol 100 mug or placebo administered 12 hours before operative hysteroscopy. MEASUREMENTS AND MAIN RESULTS Misoprostol was associated with mild abdominal cramps in four women (20%) and vaginal bleeding in another. No side effects were reported among women in the placebo group. There was no difference in baseline diameter of the cervical opening between the misoprostol group (4.0 +/- 0.1 mm) and the control group (4.2 +/- 0.2 mm). Time to dilate cervix up to 9 mm was also not significantly different (misoprostol 48.4 +/- 9.2 sec, placebo 37.7 +/- 4.1 sec). We found no difference in degree of difficulty dilating the cervix between groups. Cervical tear occurred in one patient in the misoprostol group. CONCLUSION Sublingual misoprostol 100 mug does not facilitate cervical dilatation before hysteroscopy. This may be related to leuprolides hypoestrogenic effect.

Internet use by patients seeking infertility treatment

The Internet has become a resource of health information w1x. The purpose of our study was to evaluate how infertile couples access health information on the Internet and to assess their reasons for doing so. Couples seeking consultation were asked to complete a questionnaire, entailing questions on demographics, reproductive history, general computer and Internet usage, and Internet use for fertility issues. Using 5-point scales, they were asked to rate their responses to specific questions, including their satisfaction with information available on the Internet, reasons for its use, and the impact on their decision-making process. Of the total 200 respondents, 178 (89%) used the Internet for general purposes and 89 (44.5%) for fertility-related issues. Women, high level of education and high annual income characterized those who used the Internet for reproductive reasons (Table 1). Information on fertility-related websites was obtained using search engines (91%), from fertility clinics (28.1%) or from news media (22.5%). Commercial health websites (41.6%), academic institution websites (30.3%) and fertility clinic websites (28.1%) were the three most com-

Effects of repeated treatment failure on the quality of life of couples with infertility.

OBJECTIVE To determine the impact of repeated treatment failure of clomiphene and intrauterine insemination on the quality of life of couples with infertility. METHODS A prospective comparative study involving 3 groups of 50 couples each. The first group consisted of infertile couples with repeated treatment failure (group FT), the second group consisted of infertile couples who had never attempted any medical treatment (group NT), and the third was a control group of couples with at least 1 child and no history of infertility. Participants completed a comprehensive questionnaire to assess 16 areas of quality of life. RESULTS The quality of life score of the control group was higher than the scores reported by groups NT and FT (P <.001). There was no significant difference in the quality of life score reported by group NT and group FT or between male and female partners. Among the women, a high quality of life was reported by 22% in group FT, 14% in group NT, and 54% in the control group. Among the men, a high quality of life was reported by 14% in group FT, 12% in group NT, and 60% in the control group. In contrast to their male partners, the women with repeated treatment failure placed higher importance on children and home than their counterparts who had not started the treatment (P <.05). CONCLUSION Although couples with repeated treatment failure of clomiphene and intrauterine insemination do not demonstrate a lower overall quality of life than other infertile couples beginning baseline assessment, the quality of life of infertile couples is lower than that of fertile couples.

Insulin Responses to the Oral Glucose Tolerance Test in Women of Different Ethnicity With Polycystic Ovary Syndrome

OBJECTIVE To evaluate insulin responses to the oral glucose tolerance test (OGTT) in women of different ethnic origins diagnosed with polycystic ovary syndrome (PCOS). METHODS We evaluated 92 women diagnosed with PCOS. Their ethnic origins were Western European (n = 41), Middle Eastern (n = 18), African American (n = 15), East Indian (n = 9), and South American (n = 9). The clinical diagnosis of PCOS included at least 3 of the following symptoms: menstrual disturbances (amenorrhea or oligomenorrhea); ovulatory infertility, hirsutism, and elevated serum testosterone (> or = 2.0 nmol/L); or a luteinizing hormone/ follicle-stimulating hormone ratio of > or = 3. The diagnosis was also supported by ultrasonographic changes revealing the presence of multiple small antral follicles distributed peripherally. All investigations were performed after an overnight fast on days 2 through 5 of a spontaneous menstrual cycle or progesteroneinduced withdrawal bleeding. The women underwent an OGTT with a glucose loading of 75 g. The responses of glucose and insulin to the OGTT were analyzed as the area under the curve (AUC) and were calculated with the trapezoidal method. RESULTS There were no significant differences in age or body mass index (BMI) among the different ethnic groups. All groups showed endocrine changes consistent with PCOS, but there were no differences in the hormonal levels among them. Middle Eastern women had higher AUC, glucose (P < 0.02; 95% confidence interval [CI], 0.5-3.5), and insulin (P < 0.04; 95% CI, 13.3-593.4) levels than did women with Western European origin. CONCLUSIONS Middle Eastern women with PCOS expressed different insulin responses to OGTT than did Western European women, suggesting that Middle Eastern women with PCOS had poor carbohydrate metabolism.

Lateral Distribution of Ovarian Dermoid Cyst

STUDY OBJECTIVE To determine the distribution of ovarian dermoid cysts in a large series of women. DESIGN Observational study (Canadian Task Force classification II-3). SETTING University teaching hospitals. PATIENTS Three hundred thirty-six women. INTERVENTION Evaluation of operative reports. MEASUREMENTS AND MAIN RESULTS Dermoid cysts had a mean diameter of 5.6 cm. They were present in the right ovary (48.8 %), left ovary (37.8%), and bilaterally (13.4%). Unilateral cysts were more frequent in the right ovary (56.4%) than in the left (p = 0.002, odds ratio 1.7, confidence interval 1.2-2.3). This was significantly different from the expected 50% (4.45, chi2). A similar predisposition was found when we included women with bilateral cysts (p < 0.01, OR 1.5, CI 1.1-1.9). Patient age and size of cyst did not differ between those with left and right lesions. CONCLUSION In this large cohort of women, ovarian dermoid cysts had a predisposition to a right lateral location.

Twenty-one years inside the uterus.

In 1909 a German physician described intrauterine insertion of silkworm catgut ring to prevent pregnancy. Over the years the shape of the intrauterine device (IUD) has changed from ring to T-shaped; most modem IUDs contain copper or hormones. The stainless steel ring IUD is still used in China and given the ease of worldwide travel gynecologists might encounter this type of device in practice. (excerpt)

Cost analysis of adhesion-related admissions in a Canadian teaching hospital

Intra-abdominal adhesions may cause bowel obstruction, pelvic pain and infertility w1x. Few studies have been conducted to evaluate the financial impact of adhesion-related conditions on the hospital budget. We conducted a cost analysis using the hospital administrative database. The study population consisted of patients of both genders that had undergone treatment for adhesions-related conditions between 1997 and 1999. Computerized information on the cost was available for 105 patients. Information on cost was categorized under five headings: radiology, laboratory, pharmacy, nursing and operating room (OR) costs as we previously described w2x. There were no differences in the rates of admission and the duration of hospital stay between 1997, 1998 and 1999 (Table 1). Of the total 105 patients, 64 (60.9%) were females and 41 (39.1%) were males. The admitting diagnosis was intestinal