Patrick Puttemans

The endoscopic localization of endometrial implants in the ovarian chocolate cyst

OBJECTIVE To describe the characteristics of the endometrial cyst and to locate the implants for selective biopsy. DESIGN Prospective study. SUBJECTS Fifty-one women with one or two ovarian chocolate cysts of 3 cm or more were investigated. INTERVENTIONS Laparoscopy and random biopsy versus a new technique of ovarioscopy and selective biopsy. MAIN OUTCOME MEASURE Visual characteristics and histopathology of endometrial cysts. RESULTS The clinical suspicion of an endometrioma was confirmed in a series of 59 hemorrhagic cysts by histopathology in 89% and 42%, respectively, of typical and atypical cases and in 27% of recurrent chocolate cysts in the presence of postoperative adhesions. The atraumatic technique of ovarioscopy allowed description of the typical characteristics of the inner wall of the endometrioma and location of the active implants for biopsy. Endometrial tissue was obtained by small ovarioscopy-guided biopsies in 82% of the cases versus 42% in large random biopsies. Red lesions were highly significant for a mucosa-type implant and were predominantly located at the site of invagination stigma and adhesions with the pelvic wall. CONCLUSIONS Endoscopy of ovarian chocolate cysts allows observation of typical features of the wall that differentiates it from other benign cysts of the ovary. Microbiopsies obtained under endo-ovarian endoscopy provided significantly more active, endometrial tissue than random biopsies. The data confirm that in most cases the endometrioma is formed by invagination of the cortex and that active implants are located at the site of invagination. Ovarioscopy is therefore proposed as a useful tool to differentiate in doubtful cases between a hemorrhagic functional and an endometriotic cyst and to select the sites for biopsies.

The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review

BACKGROUND Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence on this subject is lacking. METHODS We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied. RESULTS We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine insemination, starting 3 months after the surgical intervention [relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6-3.2]. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (RR = 1.9; 95% CI: 1.0-3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility when compared with those with recurrent pregnancy loss (RR = 0.7; 95% CI: 0.5-0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR = 1.7; 95% CI: 1.5-2.0). CONCLUSIONS Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.

Belgian legislation and the effect of elective single embryo transfer on IVF outcome

In order to reduce the number of multiple pregnancies following IVF, the Belgian government agreed to reimburse laboratory expenses for six IVF cycles up to the age of 42 years, in exchange for restriction of the number of embryos replaced. Data on assisted reproduction outcome before and after the introduction of this new legislation were analysed retrospectively in terms of implantation, pregnancy and multiple pregnancy rates. After the introduction of the new law, the percentage of single embryo transfer increased from 14 to 49%. Implantation rates were 25.9 and 23% respectively. There was no difference in the overall pregnancy rate before and after the introduction (36 versus 37%). Twin pregnancies, however, decreased from 19 to 3%. These findings indicate that elective single embryo transfer significantly decreases the twin pregnancy rate without a reduction in the overall pregnancy rate.

Reconstruction of the ovary containing large endometriomas by an extraovarian endosurgical technique

OBJECTIVE To describe and evaluate the surgical treatment of large ovarian endometriomas by an extraovarian endosurgical technique. DESIGN Prospective case series study. SETTING University center and tertiary referral center for endoscopic surgery. PATIENTS Patients with large ovarian endometriomas. INTERVENTION A two-step endosurgical procedure: the first step is a combined diagnostic and operative procedure confirming the diagnosis and preparing the involution of the pseudocyst and the second step includes adhesiolysis and superficial coagulation of the inverted cortex. MAIN OUTCOME MEASURES Operative findings and recurrence of endometriomas in the operated ovaries. RESULTS Sixteen patients presenting with 20 large typical ovarian endometriomas were operated using the two-step endosurgical technique. Both steps were performed on 18 endometriomas. One patient with bilateral endometriomas refused the second endoscopic procedure. The long-term follow-up showed no recurrence in the 18 ovaries that were treated by the two-step endoscopic technique. CONCLUSIONS The two-step extraovarian endosurgical technique can be applied in large typical endometriomas to reconstruct the ovary without excision and is followed by a low recurrence rate.

Potential role of endometrial stem/progenitor cells in the pathogenesis of early-onset endometriosis

The pathogenesis of early-onset endometriosis has recently been revisited, sparked by the discovery of endometrial stem/progenitor cells and their possible role in endometriosis, and because maternal pregnancy hormone withdrawal following delivery induces uterine bleeding in the neonate. The neonatal uterus has a large cervix to corpus ratio which is functionally blocked with mucous, supporting the concept of retrograde shedding of neonatal endometrium. Only 5% show overt bleeding. Furthermore, the presence of endometriosis in pre-menarcheal girls and even in severe stage in adolescents supports the theory that early-onset endometriosis may originate from retrograde uterine bleeding soon after birth. Endometrial stem/progenitor cells have been identified in menstrual blood suggesting that they may also be shed during neonatal uterine bleeding. Thus, we hypothesized that stem/progenitor cells present in shedding endometrium may have a role in the pathogenesis of early-onset endometriosis through retrograde neonatal uterine bleeding. During the neonatal and pre-pubertal period, shed endometrial stem/progenitor cells are postulated to survive in the pelvic cavity in the absence of circulating estrogens supported by niche cells also shed during neonatal uterine bleeding. According to this hypothesis, during thelarche, under the influence of rising estrogen levels, endometrial stem/progenitor cells proliferate and establish ectopic endometrial lesions characteristic of endometriosis. This New Research Horizon review builds on recent discussions on the pathogenesis of early-onset endometriosis and raises new avenues for research into this costly condition.

Salpingoscopy: a new pre‐operative diagnostic tool in tubal infertility

Summary. Endoscopy of the fallopian tube allows examination of the tubal mucosa in subfertile patients. Clinical and morphological studies have shown a high correlation between the appearance of the tubal mucosa and the ultimate outcome in terms of pregnancies. Salpingoscopy was originally performed during laparotomy for reconstructive tubal surgery. The present study describes the use of a rigid 3 mm telescope passed along the channel of the operating laparoscope to assess the mucosa of the infundibulum and ampullary segment. Lesions of the infundibulum and ampullary segment have been detected in patients with apparently normal tubes on the hysterosalpingogram and at laparoscopy. The extent of the mucosal lesions can be assessed preoperatively in patients with tubal adhesions, tubo‐cornual or isthmic lesions and hydrosalpinges.

The clinical value of salpingoscopy in tubal infertility.

A specially designed rigid salpingoscope has been developed to allow inspection of the tubal mucosa during laparoscopy. The presence and extent of intratubal adhesion formation can be evaluated more accurately by this technique than by either HSG or laparoscopy. In 22 patients with bilateral hydrosalpinges, an intrauterine pregnancy rate of 59% was achieved in the group of patients with very mild mucosal lesions and absence of mucosal adhesions.

Aromatase P450 messenger RNA expression in eutopic endometrium is not a specific marker for pelvic endometriosis

OBJECTIVE To determine whether expression of aromatase P450 mRNA in eutopic endometrium is predictive of the presence of pelvic endometriosis. DESIGN A prospective, multicenter, observational study. SETTING Four tertiary centers for reproductive medicine. PATIENT(S) Sixty subjects of reproductive age undergoing laparoscopy for subfertility exploration, pain assessment, or sterilization. INTERVENTION(S) Endometrial biopsy at time of laparoscopy. MAIN OUTCOME MEASURE(S) The expression of aromatase P450 mRNA in endometrial specimens was determined by single-tube reverse transcription-polymerase chain reaction (RT-PCR). Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) mRNA was amplified in parallel to exclude amplification failure. RESULT(S) The RT-PCR amplification was successful in 56 of the 60 biopsies (93%). Pelvic endometriosis was diagnosed in 34 patients (61%) and was strongly associated with aromatase P450 mRNA expression in eutopic endometrium. As a diagnostic marker for endometriosis, aromatase P450 mRNA expression yielded a sensitivity of 82%, a specificity of 59%, a positive predictive value of 76%, and a negative predictive value of 67%. If additional uterine pathology was taken in account, the sensitivity increased to 84%, the specificity to 72%, the positive predictive value to 87%, but the negative predictive value remained unchanged (67%). CONCLUSION(S) Although endometrial aromatase P450 gene expression is highly predictive of the presence of pelvic disease, the relative high incidence of false-negative results and lack of specificity is likely to impair clinical application.

Transvaginal hydrolaparoscopy in the treatment of polycystic ovary syndrome

OBJECTIVE To evaluate the efficacy of transvaginal endoscopic ovarian capsule drilling. DESIGN Retrospective efficacy study. SETTING Private tertiary care center. PATIENT(S) Thirty-nine PCOS patients with previously failed ovulation induction; mean duration of infertility 26.5 months (SD +/-2.6); mean age 30.38 years (SD +/-3.8); mean body mass index of 29.4 (SD +/-9.7). INTERVENTION(S) Through transvaginal hydrolaparoscopy in a 1-day clinic setting, drilling of the ovarian capsule is performed with a 5-Fr bipolar needle (Karl Storz, Tüttlingen, Germany) creating 10-15 holes of +/-0.20 mm in each ovary. MAIN OUTCOME MEASURE(S) Evaluation of feasibility, spontaneous resumption of ovulatory cycles and pregnancy rates. RESULT(S) Ovarian capsule drilling was performed in 39 patients. Six patients were lost of follow-up. In total, 25 out of 33 patients (76%) became pregnant with a mean duration between procedure and onset of pregnancy of 7.2 months (SD +/-5.4). Natural conception with or without controlled ovarian hyperstimulation and/or intrauterine insemination occurred in 13 of the 16 patients (81%). Of the 17 patients referred to our IVF program, 12 became pregnant. There were no multiple pregnancies or complications. CONCLUSION(S) The transvaginal approach for ovarian capsule drilling offers a valuable alternative to the standard laparoscopic procedure.

Clinical factors determining pregnancy outcome after microsurgical tubal reanastomosis

OBJECTIVE To evaluate pregnancy rates after tubal microsurgical anastomosis. DESIGN Retrospective study. SETTING Private tertiary care center. PATIENT(S) Two hundred sixty-one women undergoing tubal microsurgical anastomosis. INTERVENTION(S) Tubal anastomoses were performed by minilaparotomy using microsurgical principles and approximating proximal and distal tubal ends in a two-layer technique with 8-0 ethylon. MAIN OUTCOME MEASURE(S) Pregnancy outcome was analyzed for the technique of sterilization, location of anastomosis, tubal length, age, and semen parameters. RESULT(S) After exclusion of 89 patients lost to follow-up (34%) and 8 who did not attempt to conceive, 164 of the 261 patients were analyzed.The overall intrauterine pregnancy rate was 72.5%, with a miscarriage rate of 18% and a tubal pregnancy rate of 7.7%. Related to age, the cumulative intrauterine pregnancy rate was, respectively, 81%, 67%, 50%, and 12.5% for patients <36, 36-40, 40-43, and >43 years. Mean time to pregnancy was respectively 6.9, 6.2, and 12.7 months, respectively, for patients aged <36, 36-39, and 40-43 years According to the type of sterilization, intrauterine pregnancies occurred in 72% after ring sterilization, 78% after clip sterilization, 68% after coagulation, and 67% after Pomeroy sterilization. Intrauterine pregnancies and ectopic pregnancies, respectively, occurred in 80% and 3.4% in the isthmo-isthmic, 63% and 18% in the isthmo-ampullar, 75% and 8.3% in the isthmo-cornual, 100% and 0% in the ampullo-ampullar, and 60% and 0% in the ampullo-cornual anastomosis groups. Tubal length after anastomosis did not influence the pregnancy rate. In case of fertile sperm, the pregnancy rate was found to be 80%, and it decreased to 50% in case of subfertile semen. CONCLUSION(S) Our results clearly demonstrate the validity of tubal microsurgical anastomosis, establishing a quasinormalization of the fertility potential and offering the opportunity for a spontaneous conception.