M. Goldenberg

High failure rates of medical termination of pregnancy after introduction to a large teaching hospital

The success rates of medical termination of pregnancy in two time periods (2000-2001 and 2002-2003) were compared to assess the effectiveness of medical abortion introduction to a large academic tertiary medical center. The success rates were markedly reduced over time (87.0% vs. 79.3%) probably owing to the difficulty in defining clear sonographic criteria for treatment failure and the complexity of a follow-up program implemented at a large teaching hospital by a broad staff with widely varying experience and knowledge of the new procedure.

Lack of association between ovarian follicular size and number and the occurrence of multiple pregnancies in menotropin cycles

A high rate of ovarian multifollicular development and resulting multiple pregnancy remains the main problem of ovulation induction with human menopausal gonadotropins. The aim of this study was to examine a possible correlation between the number and size of ovarian follicles at the time of human chorionic gonadotropin (hCG) administration and to find parameters that can predict the occurrence of multiple pregnancies. Sixty-eight intrauterine pregnancies, 53 singletons and 15 multiple pregnancies in 51 patients, were included in this study. We found no significant difference in the mean estradiol levels, the total number of pre-ovulatory follicles, or the mean number of large, intermediate or small follicles at the time of hCG administration between women who had singleton pregnancies and those with multiple pregnancies. Our study demonstrates that estradiol levels and ovarian ultrasonography do not provide criteria for the prediction of the occurrence of multiple pregnancies in menotropin cycles.

Hysteroscopically guided transvaginal ultrasound tubal catheterization—a novel office procedure

OBJECTIVE Investigate a novel office hysteroscopic tubal catheterization therapeutic method for proximal tubal occlusion. STUDY DESIGN Prospective cohort study in a tertiary referral center. We evaluated the procedure on a group of 27 patients that were referred to our unit for proximal tubal occlusion demonstrated by hysterosalpingography, 9 (33.3%) of them with primary infertility and 18 of them (66.6%) with secondary infertility. The intervention included the usage of the modified Novy cornual cannulation set which was inserted through a 5F working cannel during an office operative hysteroscopy, followed by fallopian tube irrigation with saline-air mixture under ultrasonographic imaging. RESULTS Our series revealed no complication during or after the procedure; anesthesia was not required. One patient lost from follow-up. Of the remaining 26, 10 patients (38.4%) conceived either spontaneously or with treatment by clomiphene or gonadotropine associated with intrauterine insemination. The median time to conception was 5 months (range 4-17). CONCLUSION We therefore concluded that office hysteroscopic tubal catheterization is a simple (without anesthesia required) option for the treatment of patients suffering from proximal tubal occlusion. Fertility outcomes in our series are comparable to other treatments options for tubal catheterization. Therefore, tubal catheterization should not delay the assisted reproducted techniques if indicated but we propose to include it in a global integrated approach.

Sonographic Signs of Adenomyosis Are Prevalent in Women Undergoing Surgery for Endometriosis and May Suggest a Higher Risk of Infertility

Objectives To determine the prevalence of ultrasound features suggestive of adenomyosis in women undergoing surgery for endometriosis compared with a control group of healthy women without endometriosis. Methods Retrospective case-control study comparing women with intractable pain or infertility, who underwent transvaginal ultrasound and subsequent laparoscopic surgery, with a control group of healthy women without a previous history of endometriosis. A diagnosis of adenomyosis on TVUS was made based on asymmetrical myometrial thickening, linear striations, myometrial cysts, hyperechoic islands, irregular endometrial-myometrial junction, parallel shadowing, and localized adenomyomas and analyzed for one sign and for three or more signs. Results The study and control groups included 94 and 60 women, respectively. In the study group, women were younger and had more dysmenorrhea and infertility symptoms. The presence of any sonographic feature of adenomyosis, as well as three or more signs, was found to be more prevalent in the study group, which persisted after controlling for age, for all features but linear striations. Women in the study group who had five or more sonographic features of adenomyosis had more than a threefold risk of suffering from infertility (OR = 3.19, p = 0.015, 95% CI; 1.25–8.17). There was no association with disease severity at surgery. Conclusions Sonographic features of adenomyosis are more prevalent in women undergoing surgery for endometriosis compared to healthy controls. Women with more than five features had an increased risk of infertility.

Increased incidence of high-order and singleton conceptions after ovulation induction in winter

The possible relationship between the season of conception after ovulation induction and high-order multifetal pregnancies, was investigated. From 1975 to 1989, 111 high-order multiple births after ovulation induction were recorded at the Chaim Sheba Medical Center. This group was compared with 142 singleton pregnancies that resulted from induction of ovulation during 1989. Composite monthly cohorts of high-order multifetal pregnancies were constructed for each month of the year, and the probability of such pregnancies was estimated. The period of ovulation induction and the day of presumed conception were noted. A statistically-significant increase in the probability of high-order and singleton conceptions occurred during the winter. Our observation indicates a seasonal pattern in high order and singleton conceptions after ovulation induction.

OP31.04: Evidence of adenomyosis on transvaginal ultrasound and infertility management of patients with endometriosis selected for surgical intervention

Objectives: To assess the changes in the volume of endometriomas and rectovaginal endometriotic nodules (RVE) during 12-month treatment with norethindrone acetate (NETA) versus extended-cycle oral contraceptive. Methods: This patient preference prospective study included women of reproductive age with endometriosis. Patients received either continuous oral treatment with NETA (2.5 mg/day, Primolut-Nor® Schering, Milan, Italy; group A) or a 91-day extended-cycle oral contraceptive (LNG/EE 150/30 mcg for 84 days and EE 10 mcg for 7 days, Seasonique® Teva, Assago, Italy; group B) for 12 months. The volume of the lesions was assessed by virtual organ computer-aided analysis (VOCAL, GE Healthcare, USA). The changes in the volume of endometriomas and RVE were compared between baseline, after 6 and 12 months of treatment. The echogenicity of the endometriomas was subjectively evaluated by the ultrasonographer using a Likert scale. Results: 100 patients were enrolled in the study (50 in each group). 45 patients completed the treatment in group A and 38 in group B. In both study groups, the volume of the cysts significantly decreased at 6 (p<0.05) and 12 months of treatment (p<0.05; percentage reduction: 56.5% in group A and 55.7% in group B) compared with baseline. The decrease in the volume of the cyst between 6-month and 12-month treatment reached statistical significance in both study groups (p < 0.05). After 12 months of treatment, the echogenicity of the endometriomas significantly changed in both study groups (p<0.05). After 6 and 12 months of treatment, the volume of the RVE significantly decreased in both groups compared to baseline. There was a significant reduction in the volume of the RVE between the 6 and 12 months of treatment (p<0.05 for both study groups). Conclusions: Both NETA and Seasonique® are effective in reducing the volume of the endometriomas and RVE.

Applying a statistical method in transvaginal ultrasound training: lessons from the learning curve cumulative summation test (LC-CUSUM) for endometriosis mapping

BackgroundMethods available for assessing the learning curve, such as a predefined number of procedures or direct mentoring are lacking. Our aim was to describe the use of a statistical method to identify the minimal training length of an experienced sonographer, newly trained in deep infiltrating endometriosis (DIE) mapping by evaluating the learning curve of transvaginal ultrasound (TVUS) in the preoperative assessment of endometriosis.MethodsA retrospective study in a tertiary referral center for endometriosis. Reports and stored data from TVUS scans performed by one operator with training in general gynecological ultrasound, but not in endometriosis mapping, were analyzed retrospectively for patients who subsequently underwent laparoscopy, which served as a reference standard. The performance of TVUS was assessed for the following sites: endometriomas, bladder, vagina, pouch of Douglas, bowel and uterosacral ligaments, and correlated with laparoscopic findings. Sensitivity, specificity, PPV, NPV, and accuracy were calculated, and the operator’s diagnostic performance was assessed using the learning curve cumulative summation test (LC-CUSUM).ResultsData from 94 women were available for analysis. The learning curve using the LC-CUSUM graph showed that the sonographer reached the predefined level of proficiency in detecting endometriosis lesions after 20, 26, 32, 31, 38, and 44 examinations for endometriomas, bladder nodules, vaginal nodules, pouch of Douglas obliteration, bowel nodules, and uterosacral ligament nodules, respectively.ConclusionsLC-CUSUM allows monitoring of individual performance during the learning process of new methodologies. This study shows that a sonographer trained in general gynecologic ultrasonography, who devotes time to learn TVUS for DIE mapping, can achieve proficiency for diagnosing the major types of endometriotic lesions after examining less than 50 patients who subsequently undergo surgery in a training setting.

Feasibility and efficacy of repeated hysteroscopic cesarean niche resection

OBJECTIVE Cesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain and associated infertility. Hysteroscopic niche resection is usually a successful treatment, but can result in a failure to improve symptoms or symptoms can recur. In the present study we aim to evaluate the feasibility, effectiveness, and safety of a second hysteroscopic niche resection for patients in whom an initial hysteroscopic resection failed to improve symptoms. STUDY DESIGN This retrospective cohort study (Canadian Task Force classification II-2) hospital tell hashomer (tertiary center) included all patients who underwent a second hysteroscopic niche resection between 2011 and 2015. MEASUREMENTS Fertility,obstetric outcomes, clinical outcome and complications were compared between the first surgery and the second RESULTS: Eight patients underwent a second hysteroscopy after failure of the first hysteroscopy to resolve symptoms or after recurrence of symptoms. Abnormal uterine bleeding (AUB) was the most common symptom, occurring in all patients. The average number of days of bleeding per cycle were significantly reduced following the second surgery [14.50 (range 8-21days) vs 11.75 (range 8-20days), respectivelyp=0.009]. The second surgery improved symptoms in 6 out of the 8 patients with AUB and 1 of 2 patients with pain. There were no significant differences in fertility and obstetric outcomes between the first and the second surgery and no complications were reported during any of the surgeries. CONCLUSION Reintervention with a second hysteroscopic niche resection is both feasible and effective treatment option following a failed first attempt or recurrence of symptoms. The second surgery improved symptoms, especially AUB, with no consequent detrimental effect on obstetric outcomes on our series.

WS09‐08Sonographic and clinical characteristics of struma ovarii

Background