Rami Langer

Congenital anomalies of the müllerian system

Congenital anomalies of the müllerian system, the most common of which are uterine malformations, are associated with fertility problems. Multifactorial polygenic and familial factors are involved in their formation. The result may be deficient development (agenesis, rudimentary horn, unicornuate uterus), nonfusion (didelphys or bicornuate uterus), or defective canalization of the müllerian ducts (septate uterus). The principal diagnostic procedures include HSG, laparoscopy, hysteroscopy, and US. The clinical presentation varies from symptoms of obstruction of the menstrual flow in adolescence to hypomenorrhea and fertility problems in adult life. Repeated fetal loss, after excluding other reasons, is usually the indication for surgical intervention. Uterine septa should be resected hysteroscopically. A prophylactic cerclage has been suggested by various authors, including those of this work, in cases of symmetric uterine anomalies, especially bicornuate uteri, as a simple and effective treatment to be tried before embarking on major surgery such as metroplasty.

Improved fertility following ectopic pregnancy.

The reproductive performance subsequent to operative removal of ectopic pregnancy was examined in 154 women. They represent 64% of 242 women admitted for ectopic pregnancy between 1969 and 1979. The follow-up period averaged 42 years. The patients at risk had a conception rate of 81%, with a repeat ectopic pregnancy incidence of 7.8%, and 65% had at least one live birth. Postoperative infertility was significantly associated with (1) previous sterility, (2) coexistent periadnexal adhesions and/or tubal disease, (3) rupture of the ectopic pregnancy, and (4) older age. A statistically significant advantage of conservative over radical treatment, as regards future fertility, was demonstrated only in 53 patients with either history or findings suggestive of previously impaired fertility. Early, prerupture diagnosis and treatment, coupled with conservative and restorative measures, might account for the improved reproductive performance.

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.

Detrusor instability following colposuspension for urinary stress incontinence.

Summary. Sixty‐two patients with genuine stress incontinence (group A) and 30 women with combined detrusor instability and genuine stress incontinence (group B) had a colposuspension operation. The proportion with symptoms of detrusor instability was significantly reduced from 24% before operation to 9% after operation in group A and from 73% to 33% in group B. Urodynamically, detrusor instability developed after surgery in 17 of the 62 patients (27%) in group A whereas only 12 of the 30 women (40%) in group B had detrusor instability after surgery. No urodynamic explanation was found to explain the effect of colposuspension in relieving the symptoms of detrusor instability in some and causing them in others. Nevertheless, it is suggested that colposuspension is helpful for most patients with combined detrusor instability and genuine stress incontinence.

Long-Term (10–15 years) Follow-up after Burch Colposuspension for Urinary Stress Incontinence

Abstract: The study group comprised 127 patients who underwent a Burch colposuspension for urinary incontinence. All had undergone urodynamic investigation both pre- and postoperatively. All patients had a mean follow-up of 12.4 years (range 10–15); 109 patients had an additional urodynamic investigation at least 10 years after the operation. Following surgery there was an improvement in symptoms of frequency (P<0.001), urgency (P<0.01) and urge incontinence (P<0.001). The cure rate was 93.7%. The only significant changes found on urodynamics were the measurements of the pressure transmission ratio, which were higher postoperatively (P<0.001) and remained so after 10 years. The most frequent postoperative complications were de novo detrusor instability (16.6%) and anatomical defects (18.7%). All failed cases were found during the first postoperative year. De novo detrusor instability appeared in 12/17 patients during the first year of follow-up. Postoperative anatomical defects were found only in 4/24 patients after 5 years. Ten years postoperatively most of the anatomical defects had been detected (20/24), stressing the need for long-term follow-up.

Abortion at 18-22 weeks by laminaria dilation and evacuation.

Objective To evaluate the complications of late secondtrimester abortions (18–22 weeks) by laminaria dilation and evacuation, and the obstetric outcome of subsequent pregnancies. Methods Dilation of the cervix was achieved by repeated laminaria tent replacement. Evacuation was carried out in the outpatient clinic using general anesthesia. After the first menstrual period, all patients were invited for examination and thereafter were asked to report the outcome of subsequent pregnancies. Results One hundred seventy-one late second-trimester abortions were performed. Cervical dilation was satisfactory in 158 women (92%). Operative sonography was required in nine (5%) women. One had uterine atony. Follow-up from 150 (88%) women indicated no infection, but one woman required repeat curettage for retained products of conception. There was no indication of cervical injury on cervical internal os measurements remote from abortion. Of the 50 patients who conceived and elected to continue the subsequent pregnancies, two had premature deliveries unrelated to cervical incompetence, and all others reached term. Conclusion Late second-trimester termination by laminaria dilation and evacuation is safe and probably not associated with future adverse pregnancy outcome.

Reproductive outcome after conservative surgery for unruptured tubal pregnancy—a 15-year experience

The fertility outcome is presented in 118 patients after conservative surgery for unruptured tubal pregnancies. This patient group experienced 142 pregnancies, 127 of which were intrauterine (89.4%). The intrauterine pregnancies (IUPs) occurred in 83 patients (70.3%) and 63.5% (75/118) had live births. The recurrence rate of tubal pregnancy was 12.7%. Of the 65 patients with a normal contralateral tube 53 (81.5%) followed surgery with an IUP, 76.1% a live birth, and 7.7% a recurrent tubal pregnancy. Fifty-seven percent of the patients with a single tube followed with an IUP, and 47.6% had a live birth. The recurrence of tubal pregnancy in this group was 28.5%. Of the patients who underwent expression of tubal gestation, 60.6% followed with an IUP, and 57.5% with a live birth with no recurrence of tubal pregnancy.

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.

The value of simultaneous hysterectomy during Burch colposuspension for urinary stress incontinence.

&NA; The effect of concomitant hysterectomy during colposuspension on the cure rate of genuine stress incontinence was evaluated prospectively in 45 patients. Twenty‐two women underwent a Colposuspension only (no‐hysterectomy group) and 23 had a concomitant abdominal hysterectomy and cul‐de‐sac obliteration (hysterectomy group). Twenty‐five months postoperatively, no differences were found in the cure rate for urinary stress incontinence between the two groups (95.5 and 95.7% for the no‐hysterectomy and the hysterectomy group, respectively). In the no‐hysterectomy group, three patients (13.6%) had enterocele formation after surgery; this complication did not occur in any of the patients in the hysterectomy group.