Jamil A. Fayez

The use of CA-125 in the diagnosis and management of endometriosis

CA-125, a cell-surface antigen, was measured by a radioimmunoassay in the serum of 414 women to determine its potential usefulness in the diagnosis and management of endometriosis. In women with minimal, mild, moderate, and severe endometriosis, the mean levels (+/- standard deviation) were 13.6 +/- 6.8, 22.8 +/- 15.5, 27 +/- 17, and 50 +/- 28 U/ml, respectively, and were significantly higher than mean levels (7.8 +/- 4.1) in 46 women with a normal laparoscopic examination. Higher mean CA-125 values also were observed in acute pelvic inflammatory disease, unexplained fertility, and pregnancy and during menstruation. The mean CA-125 value in women with treated endometriosis and a negative second-look laparoscopy was significantly lower than in women with untreated endometriosis. With the use of the 95% upper limit of 16 U/ml, the test had a sensitivity of 53% and specificity of 93%. The frequencies of elevated levels in minimal, mild, moderate, and severe endometriosis were 27%, 68%, 73%, and 100%, respectively. Changes in the CA-125 levels correlated with the clinical course of endometriosis in 37 of 44 (84%) women (P less than 0.001). The determination of CA-125 levels may assist in the evaluation and treatment of women with endometriosis.

Serum CA-125 antigen levels increase during menses

Serum CA-125 antigen levels were measured by radioimmunoassay before and during menses in women with and without endometriosis. Mean CA-125 levels were significantly increased in both groups during menses. Samples obtained during menses represent a potential source of elevated levels and false positive results.

An assessment of the role of operative laparoscopy in tuboplasty.

Eighty-three patients had tuboplasty by means of operative laparoscopic techniques. The procedures performed included salpingolysis, whereby only peritubal adhesions were lysed; ovariolysis, whereby only periovarian adhesions were lysed; salpingoovariolysis, whereby peritubal and periovarian adhesions were lysed; fimbrioplasty, whereby the partially agglutinated fimbrial end was teased open; and salpingoneostomy, whereby the completely blocked fimbrial ends were opened. Patency rates were, respectively, 100%, 100%, 100%, 64%, and 31%; and pregnancy rates were, respectively, 67%, 72%, 50%, 35%, and 10%. The only complication encountered was minimal bleeding in the patients in whom salpingoneostomy was performed. These results suggest that operative laparoscopy may be the method of choice for tubal operations that involve any of the first three categories, whereas the last two categories should be used in open laparotomy techniques.

The diagnostic value of hysterosalpingography and hysteroscopy in infertility investigation

Four hundred infertile patients had hysterosalpingography and hysteroscopy as part of their infertility workup. A comparison between the findings of these two procedures was carried out to study their diagnostic value in female infertility investigation. It was found that hysterosalpingography was as accurate as hysteroscopy in the diagnosis of normal or abnormal uterine cavities while the nature of the intrauterine filling defects was accurately revealed by hysteroscopy only. It is concluded that hysterosalpingography is an important screening procedure for the diagnosis of normal or abnormal uterine cavities and that hysteroscopy should be reserved only for the confirmation and treatment of intrauterine anomalies discovered by hysterosalpingography. Therefore we look at the two procedures, hysterosalpingography and hysteroscopy, as complementary techniques.

Prevention of Pelvic adhesion formation by different modalities of treatment

This prospective study was designed to investigate the effect of glucocorticoids, promethazine (Phenergan), hyskon, heparin, and Ringers lactated solution in the prevention of pelvic adhesion formation after pelvic surgery. The patients were divided into two groups: The first consisted of 396 patients who had laparotomy for different types of pelvic surgery, and the second group consisted of 546 patients who had operative laparoscopy for different types of pelvic disease. Patients in these two major groups were divided prospectively into different subgroups with different modalities of adjuvant therapy to prevent postoperative pelvic adhesions. A second-look laparoscopy was performed for some of the patients who failed to conceive in each of these subgroups. Pregnancy rate and adhesion formation were compared between these subgroups with no statistical difference noted. It is concluded that glucocorticoids, promethazine, heparin, and hyskon have no therapeutic advantage over Ringers lactated solution in the prevention of postoperative pelvic adhesion formation.

The appendix as the cause of chronic lower abdominal pain

The records of 63 patients who had appendectomy for chronic lower abdominal pain were reviewed. Histologically 92% of the removed appendices revealed abnormality, and 95% of these patients were completely cured. It is concluded that appendicopathy does exist and could be the cause of chronic lower abdominal pain.

Comparison of different modalities of treatment for minimal and mild endometriosis

This is a retrospective study designed to compare the results of treatment of minimal and mild types of endometriosis with danazol alone, operative laparoscopy and danazol combined, and operative laparoscopy alone. The population consisted of 112 patients with minimal endometriosis and 126 patients with the mild type. Pregnancy rate and endometriosis resolution were lowest in patients who were treated with danazol alone and highest in patients treated with operative laparoscopy alone. It is concluded that in an infertile population with minimal to mild endometriosis danazol alone appears ineffective in improving the pregnancy rate or in achieving complete resolution of endometriosis. Laparoscopic surgery for the treatment of minimal to mild endometriosis seems to be a promising method of treatment.

Spontaneous abortions in women with endometriosis

Pregnancy outcomes were evaluated retrospectively in 350 women to investigate the relationship between endometriosis and spontaneous abortions. The frequency of spontaneous abortions in women with endometriosis was significantly higher than in both a fertile nonendometriosis group and an infertile group with tubal disease. There was no correlation between the severity of the endometriosis and the frequency of spontaneous abortions. After treatment, the frequency of spontaneous abortions was significantly decreased in both the endometriosis and the tubal disease group, but these values were not significantly different from each other. We conclude that high spontaneous abortion rates are a characteristic of other subgroups of women with secondary infertility and not just in women with endometriosis, and that the majority of spontaneous abortions associated with endometriosis are not caused by the condition.

Infertility surgery of the oviduct: comparison between macrosurgery and microsurgery*

The purpose of this study is to compare the results of macrosurgical and microsurgical tuboplasty procedures performed on infertility patients after other causes of their infertility were ruled out. During a 6-year period from July 1971 through June 1977, 128 macrosurgical tuboplasties were performed, and from July 1977 through July 1979, 73 cases of microsurgical procedures were performed. The senior author was the actual or first assistant surgeon in every case. For comparison, the procedures performed were divided into seven categories: salpingolysis, fimbrioplasty, salpingoneostomy, midsegment anastomosis, tubouterine anastomosis, tubouterine implantation, and combined procedures. The results of both groups were analyzed and compared. Use of the microscope improved results in all categories, particularly in anastomosis procedures. It is concluded that the microscopic techniques have a definite advantage and are recommended for use in all tuboplasty procedures.

Serum CA-125 in the evaluation of benign adnexal cysts

Because serum CA-125 concentrations are increased in women with endometriosis, our objective was to determine whether CA-125 levels could be used to differentiate endometriotic from nonendometriotic benign cysts. During a 2-year period, all women who had an endometrioma (n = 33) or a nonendometriotic cyst (n = 27) that was greater than or equal to 4 cm were included. Serum CA-125 levels were measured by an immunoradiometric assay, and the mean concentrations in women with an endometriotic cyst increased as the diameter of the cyst increased. The mean CA-125 concentrations in women with cysts greater than or equal to 4 cm were 53 +/- 2 U/ml in 19 women with an endometriotic cyst, 11 +/- 1 U/ml in 20 women with a nonendometriotic cyst, and 15 +/- 1 U/ml in 7 women with a nonendometriotic cyst and endometriosis. In the fluid of 10 endometriomas, the mean CA-125 concentration was 290 +/- 94 X 10(3) U/ml (range 10 to 900 X 10(3) U/ml). With cysts diameters greater than or equal to 4 cm, 19 of 19 women with endometriotic cysts, zero of seven women with nonendometriotic cysts and endometriosis, and zero of 20 women with nonendometriotic cysts had CA-125 concentrations greater than or equal to 20 U/ml (99% upper normal limit). We conclude that serum CA-125 determinations offer an excellent method to differentiate endometriotic from nonendometriotic benign cysts.