Mordechai Pansky

Ovarian pregnancy: A report of twenty cases in one institution

A series of 20 cases of primary ovarian pregnancy that were diagnosed and treated in one institution is reported. The prevalence rate of 1:3600 deliveries seems to be increasing in past years and comprises 3.3% of all extrauterine pregnancies. Clinical presentation, possible pathogenesis, diagnostic steps, preferred management, and future fertility are detailed. Inasmuch as all our 18 fertile patients used an intrauterine contraceptive device before the operation, special emphasis is made on the controversial relationship between use of intrauterine contraceptive devices and ovarian pregnancy.

Local methotrexate injection: A nonsurgical treatment of ectopic pregnancy

Twenty seven patients with unruptured tubal pregnancy were selected for nonsurgical treatment with the use of one injection of 12.5 mg of methotrexate into the ectopic site at laparoscopy. No adverse reactions were observed. In three patients (11%), a laparotomy was performed because of rising beta-human chorionic gonadotropin titers. In the other patients, serum beta-human chorionic gonadotropin levels decreased to the nonpregnant range with no further intervention, and the patients recovered uneventfully. This method is suggested as an alternative to surgery in selected cases of early unruptured tubal pregnancy.

Prediction of in vitro fertilization outcome by sperm penetration assay with TEST-yolk buffer preincubation *

OBJECTIVE To evaluate sperm penetration assay (SPA) value as a screening tool before in vitro fertilization (IVF). DESIGN Follow-up study comparing sperm variables and IVF outcome. SETTING Infertile couples in an academic research environment. PATIENTS, PARTICIPANTS Two hundred forty-one infertile couples scheduled for IVF. INTERVENTIONS Sperm penetrating assay with cold Tes-TRIS (TEST) Yolk buffer semen preincubation and IVF. MAIN OUTCOME MEASURES Percent of egg penetration recoded into poor and good category (0% to 20%, 21% to 100%) and compared with fertilization, embryo transfer, and pregnancy rate (PR) in IVF, as well as sperm count motility and morphology. RESULTS Sperm penetrating assay predicted fertilization with a high negative (74%) and positive (82%) predictive rate and good specificity value (0.96). One of 31 patients in the poor SPA category (3%) fertilized less than 50% of eggs; no pregnancy occurred. In the good SPA category, 87 of 210 patients (41%) fertilized greater than or equal to 50% of eggs with 34.3% PR. Sperm penetrating assay correlated better with fertilization rate than did sperm count and motility but not morphology. CONCLUSIONS Sperm penetrating assay is a useful screening assay before IVF together with sperm morphology.

Reproductive outcome after laparoscopic local methotrexate injection for tubal pregnancy

OBJECTIVE To evaluate reproductive outcome after laparoscopic local methotrexate (MTX) injection for tubal pregnancy. DESIGN Follow-up was performed after 77 women were treated with local MTX injection between January 1, 1987 and December 31, 1990. SETTING Department of Obstetrics and Gynecology in a university medical center. MAIN OUTCOME MEASURES Concise patient details about tubal patency in hysterosalpingography, pelvic findings at laparoscopy or laparotomy performed after the treatment, and the intrauterine and extrauterine pregnancy rates (PRs) are given. RESULTS Intrauterine PR of 67% and extrauterine PR of 13% were achieved. CONCLUSION Local MTX injection does not modify tubal or pelvic anatomy and does not impair subsequent reproductive performance.

TUBAL PATENCY AFTER LOCAL METHOTREXATE INJECTION FOR TUBAL PREGNANCY

Tubal patency was investigated by hysterosalpingography in 21 of 37 patients with unruptured tubal pregnancy treated by local methotrexate injection at laparoscopy. 18 of the 21 patients had bilateral tubal patency, and the only tube of a patient with a single fallopian tube was also patent. 6 subsequent intrauterine pregnancies have so far been recorded. Local methotrexate injection into the tubal pregnancy may provide an efficient and safe alternative to surgery in early unruptured ectopic pregnancy.

Prevalence of genital chlamydia and mycoplasma infection in couples attending a male infertility clinic

To investigate the prevalence of genital mycoplasma (Ureaplasma urealyticum andMycoplasma hominis) andChlamydia trachomatis infections in infertile and fertile couples, 135 infertile couples from a male infertility clinic and 88 fertile couples from a prenatal care clinic were randomly screened. Semen, urethral and cervical smears were cultured for genital mycoplasma and chlamydia. Antichlamydia IgA, IgG and IgM antibodies were tested in blood and semen. Although the overall prevalence ofUreaplasma urealyticum was higher than that ofMycoplasma hominis, the prevalence ofMycoplasma hominis was significantly higher in the infertile men and women. The prevalence ofChlamydia trachomatis, positive culture was higher in infertile couples, but this difference was not significant. The prevalence of serum-specific IgG was significantly higher in infertile than in fertile women (11.9 vs 3.4%,p<0.05). Specific semen IgA was significantly higher in infertile than in fertile men (8.9 vs 1.1%,p<0.015). A low rate of concordance between partners was found inMycoplasma andChlamydia culture, and in the same patient between seminal IgA and urethral culture. In conclusion it is necessary to check both culture and serology findings in both partners.

Current management of ruptured corpus luteum

The objectives of the study are to assess current management of the rather frequent event of ruptured corpus luteum. Special emphasis is made on the value of ultrasonography, laparoscopy and culdocentesis in deciding appropriate treatment. A series of 70 patients with ruptured corpus luteum diagnosed and treated during a period of 6 years in one institution in Israel is reported. Eighteen patients with concurrent ruptured corpus luteum and ectopic pregnancy are included. Abdominal pain, the most prevalent presenting symptom, has no typical characteristics. The correlation between large amount of fluid as observed by ultrasound and the finding of > 250 ml of blood at laparotomy is very high. Culdocentesis was performed in only 21 patients. Surgical intervention (laparoscopy, laparotomy following laparoscopy or direct laparotomy) was carried out in 58 patients (83%). The remaining 12 cases were handled by observation only. Forty patients required laparotomy in whom 17 underwent wedge resection. We conclude that observation is sufficient treatment in hemodynamically stable patients, without severe abdominal pain and in the presence of a small amount of pelvic fluid demonstrated by ultrasound. When a large amount of fluid is observed and/or in the presence of severe abdominal pain laparoscopy should be performed on admission. Direct laparotomy is mandatory in case of circulatory collapse.

Balloon cervical ripening with extra-amniotic infusion of saline or prostaglandin e2: a double-blind, randomized controlled study

Objective To compare extra-amniotic infusion of diluted prostaglandin (PG) E2 solution with saline infusion in balloon cervical ripening and labor induction. Methods Women with pregnancy complications and Bishop scores of 3 or lower (n = 116) were assigned randomly to receive extra-amniotic infusion (1 mL/minute) of normal saline or PGE2 in saline (0.5 μg/mL) through a Foley catheter with a 30-mL inflated balloon. We induced labor using intravenous oxytocin only when labor had not developed by 6 hours after balloon expulsion. Analysis was by intent-to-treat. We assessed ripening efficiency and course of labor in women who had spontaneous balloon expulsion (n = 110) and trial of labor (n = 107), respectively. Results Ripening with PGE2 was associated with significantly shorter mean (± standard error of the mean [SEM]) time for balloon expulsion (4.7 ± 0.4 versus 6.5 ± 0.6 hours) and with significantly higher Bishop scores (P < .002), compared with ripening with saline. In the PGE2 group, rates of labor induction (15%) and oxytocin use (37%) were significantly lower than in the saline group (51% and 72%, respectively). The groups did not differ significantly in other labor abnormalities, labor duration, mode of delivery, birth weight, Apgar scores, and puerperal morbidity. Conclusion Cervical ripening by extra-amniotic balloon and PGE2 infusion is faster and more effective than by balloon and saline infusion, resulting in a higher rate of spontaneous labor and a lower rate of oxytocin use.

Long-term follow-up (5-20 years) after uterine ventrosuspension for chronic pelvic pain and deep dyspareunia.

Objective: To examine the long-term outcome of patients undergoing uterine ventrosuspension for chronic pelvic pain and deep dyspareunia. Methods: Eighty-two patients, presenting with retroverted uterus, pelvic pain and deep dyspareunia, underwent uterine ventrosuspension by laparotomy or laparoscopy during the period from 1981 to 1996. Only patients (56) with no pelvic pathologic condition, as identified intraoperatively, participated in the study. At the beginning of the year 2002, 41 out of 56 patients (73.2%) were attained by telephonic questionnaire, and they were asked to refer to the uterine ventrosuspension procedure. Results: Patients’ average age was 32.3 years, and the mean duration of preoperative symptoms was 3 years. The mean follow-up period was 12 (range 5–20) years. The initial improvement in preoperative symptoms was observed in 70.7% of patients, whereas the final improvement was observed in 46.3% of patients, with no significant difference comparing the approach of laparotomy versus laparoscopy. Hysterectomy after uterine suspension was performed in 12.1% of patients (4.3% after laparotomy and 22.2% after laparoscopy). Twenty-three patients (56.1%) would recommend this operative procedure to others. Conclusion: The long-term outcome of patients undergoing uterine ventrosuspesnion approximates to 50% success rate, with no significant difference comparing the approach of laparotomy versus laparoscopy.

Hormonal Changes Related to Impairment of Cervical Mucus in Cycles Stimulated by Clomiphene Citrate

Summary: The levels of luteinizing hormone (LH), follicular stimulating hormone (FSH), 17‐oestradiol (E2), progesterone (P), and testosterone (T) were determined for the early, midfollicular and periovulatory phase of spontaneous and clomiphene citrate (CC) induced cycles in 5 patients who responded with appearance of hostile cervical mucus (Group A) and 5 patients whose cervical mucus remained unchanged during the same treatment (Group B). The patients with hostile mucus were further investigated during a third cycle stimulated by CC and ethinyloestradiol (EE). Patients treated with CC for induction of ovulation who developed hostile cervical mucus showed higher levels of LH and T in the midfollicular phase of the menstrual cycle and significantly higher levels of T in the periovulatory period compared to patients with unchanged mucus. EE treatment induced a drop in the elevated LH and T levels and improved the cervical score. No change in E2 levels was noted. A direct effect of EE on the cervical glands together with the centrally mediated lowering of serum T are suggested to be responsible for improving the cervical mucus.