Igno Siebert

Luteal phase support in in vitro fertilization : Meta-analysis of randomized trials

Objective: To determine if luteal phase support improves the pregnancy rate in in vitro fertilization (IVF) cycles. Design: A meta-analysis of randomized trials of luteal phase support was carried out with the main outcome measure being the pregnancy rate per cycle. Results: Fifty-nine trials were evaluated. Eighteen trials met the inclusion criteria. Five main themes were identified: human chorionic gonadotropin (hCG) versus progesterone; progesterone versus progesterone and hCG; progesterone versus placebo; hCG versus placebo, and hCG versus progesterone versus no support. Conclusion: Luteal phase support is definitely indicated in IVF treatment cycles. This meta-analysis favored hCG above progesterone as luteal phase support with respect to pregnancy rates. Further prospective randomized trials are needed to determine a definite consensus with respect to the duration of luteal phase support in IVF cycles.

Postmenopausal Bleeding: A Diagnostic Approach for both Private and Public Sectors

Objective: To assess the optimal diagnostic approach to women with postmenopausal bleeding by comparing transvaginal ultrasound and endometrial sampling with office hysteroscopy. Methods: A prospective collective study was performed on 102 consecutive patients with postmenopausal bleeding who were evaluated by ultrasound measurement of the endometrial thickness (EL), endometrial sampling by Accurette® and outpatient hysteroscopy and directed biopsy. Results: Accurette was inadequate for histological diagnosis in 65 of 136 samples and many repeat investigations were required. In all 16 cases of endometrial polyps, ultrasound measurement of the EL was ≧4 mm and hysteroscopy confirmed the findings. Accurette detected only 5 polyps. All 7 cases of endometrial hyperplasia were detected using an EL of ≧4 mm and hysteroscopy confirmed the findings. Accurette failed to detect 5 out of 7 cases of endometrial hyperplasia. Five cases of endometrial cancer were diagnosed: all had an EL ≧4 mm but were inadequately sampled for diagnostic purposes in 3 cases. A definitive diagnosis was made on hysteroscopy in 4 cases (1 patient did not have a hysteroscopy). Conclusion: Accurette is not a good sampling device for the diagnosis of postmenopausal bleeding. An ultrasound measurement of the EL ≧4 mm in patients with postmenopausal bleeding warrants further investigation. Outpatient office hysteroscopy is an accurate and sensitive modality to employ as a first line investigation for definitive diagnosis.

An evidence-based approach to recurrent pregnancy loss

Recurrent pregnancy loss (RPL) can be defined as more than two to three consecutive miscarriages before 24 weeks’ gestation. A literature review was done to provide an evidence-based approach to RPL, identifying the risk factors and causes and also looking at the various special investigations that form part of the work-up and trying to assess which have been proven to be effective or of negative impact, and which of the management options lead to a better outcome. We concluded that the following special investigations should be part of the work-up for all patients with RPL: (i) genetic counselling and karyotyping of the abortus; (ii) anticardiolipin antibodies and lupus anticoagulant testing must be done on two occasions, 6 - 8 weeks apart; (iii) all patients qualify for a pelvic ultrasound scan and hysteroscopy; (iv) syphilis testing must be done routinely; and (v) testing of thyroid function and glucose monitoring/glycosylated haemoglobin (HbA1c) measurement must be done in all patients with a history of thyroid disease or diabetes mellitus, or clinical manifestations thereof. In approximately 50% of couples the cause of RPL remains unexplained, even after evaluation.

Fallopian Tube Reanastomosis by Laparotomy versus Laparoscopy: A Meta-Analysis

Objective: To compare efficacy of sterilization reversals by laparotomy versus laparoscopy. Design: Meta-analysis. Search Strategy: Electronic searches were carried out for randomized controlled trials and retrospective and prospective clinical studies. Search engines such as PubMed, Science Direct, Medline and the Cochrane database were made use of. Our restrictions were English human studies published from 1989 to January 2010. Interventions: Microsurgical tubal reanastomosis performed comparing laparoscopy with laparotomy using a microsurgical technique. Outcome Measures:Primary: overall pregnancy rates, including positive clinical pregnancy, intrauterine and ectopic pregnancy rates. Secondary: surgery time. Results: Three retrospective comparative studies were retrieved from international data that investigated laparotomy versus laparoscopy. A total number of 184 patients were included, 88 and 96 respectively undergoing laparoscopy and laparotomy. Pregnancy rates achieved by laparoscopy ranged from 65 to 80.5% (mean 74.43%) and by laparotomy from 70 to 80% (mean 71.33%). A subanalysis of two of the three comparative studies show that laparoscopy reversal surgery requires a statistically significant longer operative time than does laparotomy (p < 0.00001). Conclusions: There is no difference between the laparoscopy and laparotomy approach to tubal reanastomosis when regarding overall pregnancy rates, intrauterine and ectopic pregnancy rates.

Rare case of perplexing ovarian endometriosis

OBJECTIVE To document a rare case of coexisting endometriosis and mature cystic teratoma in the same ovary. DESIGN Case report. SETTING Gynecology unit in a tertiary training and teaching hospital in Cape Town, South Africa. PATIENT(S) A 30-year-old healthy nulligravida woman with a large ovarian tumor. INTERVENTION(S) After a basic examination, a diagnostic and management laparotomy was performed. A unilateral oophorectomy and staging laparotomy were performed. MAIN OUTCOME MEASURE(S) Final diagnosis of a complex ovarian tumor. RESULT(S) Histologic analysis confirmed endometriosis of the pelvis and concomitant compound pathology in the right ovary, which included endometriosis, mature teratoma, and mucinous cystadenoma. CONCLUSION(S) Co-existence of varied pathology in a single organ presents a challenge to the pathologist and the clinician. Accurate clinical (i.e., surgical) assessment and decisive histologic verification forms a critical part in this process. This case of coexisting endometriosis and teratoma in a single ovary is, to our knowledge, only the third case reported in literature.

A rare case of a synchronous endometrioid adenocarcinoma of the ovary and of eutopic endometrium in a patient with endometriosis

Malignant transformation of endometriosis is a rare, documented complication of endometriosis. Endometriosis shares characteristics with malignancy and has biological systems central to its progression and malignant transformation. Evidence has emerged on the role of the fallopian tube in endometriosis and ovarian cancer. This has led to a paradigm shift in how the fallopian tube is viewed. This is a case of endometrioid adenocarcinoma of the ovary arising from endometriosis, occurring synchronously in eutopic endometrium. There is agreement on the risk factors of malignant transformation of endometriosis which should assist in clinical vigilance and screening of ovarian cancer associated with endometriosis. Although most ovarian malignancies require aggressive therapy, endometriosis-associated ovarian cancer appears to be less aggressive, is diagnosed early and has a better prognosis and overall survival.

Laparoscopic surgery for rectovaginal endometriosis: a retrospective descriptive study from a single centre

Introduction Rectovaginal endometriosis is a form of deep infiltrating endometriosis and accounts for 5%-10% of cases. It is a very difficult to treat and can be associated with severe complications. Objectives The aim was to document the outcomes of patients undergoing laparoscopic surgery for rectovaginal endometriosis. Methods A retrospective audit of 112 consecutive women undergoing laparoscopic surgery for rectovaginal endometriosis at Vincent Pallottis Aevitas Fertility Clinic was undertaken. Women were identified from a surgical database using medical aid coding and a review of case notes. Patients were telephonically contacted to gather missing information and to assess further outcomes. Results The majority of surgeries were performed using the shaving technique, in keeping with international trends, whilst fourteen cases required a segmental resection owing to extensive disease. Complications included rectovaginal fistulas (3 cases), bowel injuries (2 cases), ureteric injury (1 case), a pelvic abscess (1 case), a blood transfusion (1 case) and the need for three urgent re-operations. Of the 71 patients desiring fertility, 39 (54.9%) fell pregnant. Twenty-seven (69.2%) were spontaneous conceptions. Conclusions Our outcomes are in keeping with complication rates quoted in the international literature. In trained hands, laparoscopic surgery at our unit is a valid option in the management of rectovaginal endometriosis with similar complication rates and outcomes to international standards.

Osseous metaplasia of the endometrium : case report

Osseous metaplasia should be kept in mind as a rare cause of failure to conceive, even in patients with primary infertility. We report a case of osseous metaplasia of the endometrium as a cause of primary infertility and present a literature review. The condition may be more common than expected or generally accepted, and should be kept in mind even in patients with primary infertility. Hysteroscopy is an effective diagnostic as well as treatment modality. The human endometrium contains populations of epithelial progenitor cells and mesenchymal stem cells. These cells are multipotent but rare, and are the most likely origin of the endometrial ossification. The cells can also differentiate into adipogenic and chondrogenic lineages.

A new approach to tubal re-anastomosis in South Africa

To the Editor: Contraception by means of fallopian tube sterilisation is the most common method used worldwide, and it is estimated that on average 138 million women of reproductive age are sterilised globally each year. Several studies have indicated that the incidence of tubal re-anastomosis in previously sterilised women is 1 - 2%. Laparotomy is currently seen as the gold standard for fallopian tube reversal, and this was the case at Tygerberg Hospital from 1982. However, laparoscopy has been extensively explored as a viable alternative over the past 3 decades. This technique requires expert endoscopic surgical skill. Recently laparoscopy was instituted as a reversal method at our facility owing to our interest in endoscopy.