John J. Sciarra

Intrauterine adhesions: Hysteroscopic diagnosis, classification, treatment, and reproductive outcome

One hundred eighty-seven patients were evaluated and treated by hysteroscopy over a 10-year period. To assess therapeutic prognosis, these patients were classified according to the extent of uterine cavity occlusion seen on hysterosalpingography and the type of intrauterine adhesions observed at hysteroscopy. Forty-three patients had mild or filmy intrauterine adhesions, 97 had moderate or fibromuscular adhesions, and 47 patients were classified as having severe connective tissue adhesions. After hysteroscopic treatment, normal menstruation was restored in 88.2% of patients who had menstrual abnormalities including amenorrhea, hypomenorrhea, and dysmenorrhea. Among the 187 patients, 143 women achieved pregnancy; of those, 114 (79.7%) achieved a term pregnancy, 26 (18.2%) had a spontaneous abortion, and 3 (2.1%) had ectopic pregnancies. The reproductive outcome correlated with the type of adhesions and extent of uterine cavity occlusion, ranging from a term pregnancy rate of 81.3% in patients with mild disease to 31.9% in patients with severe disease.

Long-Acting Contraceptive Delivery Systems

In May 1983 some 115 participants representing 16 countries attended the International Workshop on Long-Acting Contraceptive Delivery Systems sponsored by the Program for Applied Research on Fertility Regulation. Long-acting contraceptive delivery systems are relatively new in clinical research although some long-acting injectables have been used for nearly a decade. The worldwide use of long-acting injectable preparations (primarily Depo-provera and norethindrone enanthate) is estimated to be about 4 million. In the US and Europe between 150000 and 200000 couples control their fertility with a progesterone-releasing IUD. These are small numbers compared to other methods. Although the injectables have a number of advantages--for example prolonged effectiveness use unrelated to coitus a high degree of acceptability in most cultures and reversibility--there are significant disadvantages. The 2 important ones are menstrual cycle disruption including secondary amenorrhea and unanswered questions about long-term safety. There is no best single method for all couples. Many scientists believe that an improved injectable or implantable method could enter wide-scale human use in many countries within 5 years. Chapters are arranged under 10 broad headings: 1)acceptability of long-acting contraception; 2)polymeric delivery systems for contraception; 3)injectable/implantable long-acting contraceptive systems; 4)long-actingvaginal contraceptive delivery systems; 5)endometrial response to steroids; 6)fetal and child development issues; 7)long-acting contraceptive delivery systems; clinical studies; 8)long-acting contraceptive delivery systems: Norplant; 9)other long-acting contraceptive systems; and 10)long-actingcontraceptive delivery systems: additional clinical studies. Also included are addresses of contributing authors and workshop participants.

Endometriosis: Treatment Strategies

Abstract: Endometriosis is often a perplexing medical condition for both the physician and the patient. Accordingly, development of treatment strategies based on the needs of the individual patient is highly desirable. Although endometriosis has been part of the clinical practice for almost a century, many questions remain relating to the relationship between endometriosis and infertility as well as endometriosis and pelvic pain. Endometriosis is a disease of reproductive‐age women, and it is now well recognized that a genetic susceptibility appears probable. The prevalence in the general population has never been clearly established. Factors to consider in management include the age and reproductive desires of the patient, the stage of the disease, and, most importantly, the symptoms. Therapeutic options include no treatment, medical therapy, surgery, or combination therapy. Oral contraceptives, androgenic agents, progestins, and gonadotropin releasing hormone (GnRH) analogs have all been used successfully, although at the present time, the latter preparations are the most popular medical therapy for endometriosis. Leuprolide acetate, goserelin acetate, and nafarelin acetate are all effective agents. Surgical therapy is appropriate, especially for advanced stages of the disease. Laparoscopy is an effective surgical approach with the goal of excision of visible endometriosis in a hemostatic fashion. Since endometriosis is a chronic condition, it is not uncommon for recurrences to occur. While endometriosis remains an enigmatic disease, the introduction of new pharmacologic agents, such as GnRH analogs and newer endoscopic methods of surgical treatment, have facilitated and improved the overall management of this disease.

Hysteroscopic treatment of the septate uterus.

Twelve patients with symptomatic septate uteri underwent hysteroscopic division of the uterine septum, monitored by concomitant laparoscopy, over a six-year period. The preoperative reproductive performance included 42 pregnancies, with only three viable deliveries. Ten of the 12 patients conceived within one year after therapy, and eight of these patients delivered a live infant at term. Two patients had a spontaneous abortion at six and eight weeks after therapy, respectively, but in each, a subsequent pregnancy was carried to term. Three patients are currently pregnant (eight, 12, and 18 weeks). Two patients have not as yet conceived. Two patients required a second hysteroscopic operation because a partial residual septum was observed on the posttreatment hysterogram.

Human placental lactogen (HPL) and placental weight

Abstract To investigate the value of maternal human placental lactogen (HPL) as an index of functioning trophoblast, a controlled series of 111 pregnant patients was studied. Concentrations of HPL in maternal and fetal blood at term were determined by radioimmunoassay, and these values were correlated with placental weight and the weight of the newborn at delivery. Mean maternal HPL at term was 3.98 μg per milliliter (range, 0.4 to 15.6) and mean fetal HPL was 58.9 mμg per milliliter (range, 0.2 to 266.4). The rank correlation between maternal HPL and placental weight was 0.34 which, although positive, was too low to be of predictive value.

Infertility: An international health problem

When considering infertility as a health problem, the above definition is too restrictive for a number of reasons. First, for women aged 30-35 who have voluntarily delayed childbearing, a waiting period of 1 year or more may be psychologically unacceptable. In this situation, consultation and investigation may be offered sooner if the couple presents with this request. Second, in addition to the treatment of primary and secondary infertility, the spectrum of human infertility therapy today includes the prevention of pregnancy loss, including the problems associated with repeated abortion, as this problem can be equally distressing to women, who may be able to conceive but not able to maintain a pregnancy. Finally, the

Intrauterine contraception: advances and future prospects.

This book describes the development and clinical experience of use of many types of intrauterine devices for the prevention of conception including reports from Canada Western Europe the US Singapore China Japan and India. It contains extensive discussion on regulatory and policy issues related to the use and prescription of IUDs as well as frank discussions of the medical risks and complications associated with use of IUDs such as pelvic inflammatory disease uterine perforation and ectopic pregnancy. In addition research areas of material choice other hormone-releasing devices and material shape of the device are included.

Risks, Benefits, and Controversies in Fertility Control

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Hysteroscopy: A clinical experience with 320 patients☆

Hysteroscopy has added a new dimension to the management of patients with common clinical problems, increasing the accuracy of diagnosis and serving as an adjunct in treatment of intrauterine conditions. This report summarizes the hysteroscopic experience with 320 selected patients, 104 in the reproductive age group with abnormal uterine bleeding, 91 who underwent hysteroscopy for location and retrieval of intrauterine contraceptive devices, 36 with primary or secondary infertility, 36 with postmenopausal bleeding, and 15 with uterine leiomyomas. Paracervical block anesthesia was used successfully in 214 patients. General anesthesia was used in the remainder because of planned additional surgical intervention. Uterine distention was achieved with D5W in 270 patients, with dextran 32% in 30 patients, and with CO2 gas insufflation in 20 patients. In 71.6 per cent of the patients,visually recognizable or pathologically suspicious intrauterine abnormalities were found. This study further demonstrated the utility of hysteroscopy in diagnosis of endometrial polyps, uterine submucous leiomyomas, uterine malformations, and intrauterine adhesions. Hysteroscopy was also helpful in taking directed biopsies of selected areas of the endometrium in patients with adenomatous hyperplasia and early adenocarcinoma of the endometrium and helpful in removal of intrauterine foreign bodies and evaluation of the recently pregnant uterus when there was a question of persistent pregnancy. Hysteroscopy is a safe ambulatory procedure that is appealing to both patient and gynecologist in its economy and simplicity.

Sexually transmitted diseases: global importance

The worldwide incidence of sexually transmitted diseases (STDs) including the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) continues to increase and represents a major public health problem especially in the developing world causing infertility and ectopic pregnancy. Prevention of the spread of STDs, along with early detection and appropriate therapy has the potential to minimize the reproductive tract damage of these infections and simultaneously improve the health of women in all areas of the world.