S. Michalas

Adhesions: Laparoscopic Surgery versus Laparotomy

Abstract: This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

USE OF MISOPROSTOL FOR THE TERMINATION OF SECOND TRIMESTER PREGNANCIES

Abstractu2002Surgical termination of pregnancy is of high risk for the woman’s health and safe medical ways are required. The use of prostaglandins may substantially reduce this risk. The efficacy and safety of misoprostol as a medication for the termination of the second trimester pregnancies were studied. During a 15-month period ninety-eight healthy pregnant women (13–24 weeks) wishing to terminate their pregnancy due to medical reasons participated voluntarily in this study. Misoprostol was administered 400 µg per os and 400 µg vaginally. Dose was repeated every 6 hours until adequate contractions and cervical ripening were achieved. Outcome measures included successful termination rates, mean expulsion time and side effects of the medication. The efficacy of the method was as high as 91.8% (90/98 cases 95%, CI 86–97%). Mean expulsion time was 10.2 h (range 3–23.4 h) for primigravida and 9.2 h (range 2.5–22.2 h) for multigravida. In 9 cases (9.2%) placenta remnants and in 8 (8.2%) placenta retention were found. Most common side effect was shivering in 17.3% of cases, vomiting and nausea (10.2%), headache and dizziness (7.1%), abdominal pain (79.6%), while diarrhea was noticed in 4.1%. The high efficacy and low incidence of side effects make misoprostol a useful alternative method for medical termination of second trimester pregnancies.

Endometriosis and Reproductive Disorders

Abstract: The classic concept of endometriosis as a cause of infertility is challenged. Traditionally, both surgical and medical therapy have focused on alleviation of symptoms, prevention of disease progression, and promotion of fertility. In spite of significant developments in medical and surgical approaches, the optimal therapy for treating endometriosis‐associated infertility has yet to be established. The relationship between prevalence of fecundity and stage of the disease was studied according to the type of management. Of 151 women who were consecutively proved by laparoscopy to have endometriosis stage I and II, operative laparoscopy was performed in 49, medical treatment in 59, and expectant management in 43 cases. During a 24‐month period, the cumulative pregnancy rates were 36.7%, 30.5%, and 20.9%, respectively. Survival analysis over the 20 weeks of pregnancy showed that the probability of carrying the pregnancy beyond this week was 30.6%, 25.4%, and 16.2%, respectively. Of 64 patients with advanced disease, 34 (53%) became pregnant during the 2‐year follow‐up period. A significantly increased pregnancy rate was found for the first year as compared to the second (76% vs. 24%). The existence of adhesions affected adversely the outcome of the treatment when early achievement of pregnancy is considered. Diagnosis and treatment of endometriosis was beneficial for the infertile women. Laparoscopic surgery seems to be the best treatment in these cases, as it increases the fecundity and involves minimal risk.

Results of controlled ovarian stimulation for ART in poor responders according to the short protocol using different gonadotrophins combinations

IntroductionImproving pregnancy rates in intricate cases of ovarian stimulation remains a challenge during IVF and intracytoplasmic sperm injection (ICSI). Different protocols of ovulation induction have been proposed.MethodsThe short protocol of ovarian stimulation using recombinant follicle-stimulating hormone (rFSH) with or without the use of luteinizing hormone (LH) in IVF or ICSI outcome in patients with many failed attempts and maternity age ≥37xa0years was investigated. The prognostic significance of high but normal values of dayxa03 serum FSH concentrations was also evaluated.ResultsResults show that FSH levels of >9xa0mIU/ml are associated with poor results even with the use of human menopausal gonadotrophin (HMG). Results were generally comparable when rFSH was used alone or in combination with HMG, except for the quality and the number of embryos transferred, the later being better in the rFSH + HMG group.ConclusionIn conclusion intricate cases have good chances for achieving a pregnancy using the short protocol and the outcome is further improved when LH is added from the beginning of ovarian stimulation. A slight elevation of dayxa03 FSH seems to be a strong prognostic factor for a poor outcome.

Clinical implications of the ovarian/endometrial renin-angiotensin-aldosterone system.

Abstract: New organ‐specific functions of angiotensin II have recently been described: the importance of its role in the regulation of secretory epithelial function in many tissues including components of the reproductive tract has been documented. The source of angiotensin II in these tissues is the reproductive tract itself, and there is considerable evidence to suggest a distinct renin‐angiotensin‐aldosterone system in the ovary and uterus. Two main subtypes of angiotensin II receptors are recognized as angiotensin‐receptor I and II, according to their sensitivity to the angiotensin II antagonists. However, the presence of angiotensin II receptors in the male and female reproductive tract suggests a multiplicity of roles that are unrelated to their primary functions or to each other. The renin‐angiotensin‐aldosterone system is a major determinant of sodium balance in pregnancy. More recently RT‐PCR methods have revealed angiotensinogen transcription in the smooth muscle of spiral anteries of the decidua; a specific allele of this gene may be associated with hypertension in pregnancy as well as in pre‐eclampsia. We investigated the evolution of plasma renin activity and aldosterone levels during normal and hypertensive pregnancy. Both were found to increase progressively during all three trimesters of normotensive pregnancy. Plasma renin activity in hypertensive women remained unchanged during all three trimesters of pregnancy. Plasma aldosterone levels in hypertensive women increased progressively during all three trimesters of pregnancy. However, plasma aldosterone levels remained significantly lower than the ones of normotensive pregnant women. These increased aldosterone levels were noticed despite unchanged renin levels. Further clinical studies investigating the renin‐angiotensin‐aldosterone system in the pathogenesis of pregnancy hypertension are needed. A renin‐independent role of aldosterone in this pathological entity is suggested.

Cervico-isthmic pregnancy: an extremely rare case diagnosed during labour

This case report describes a cervico-isthmic pregnancy ending in a live vaginal birth at 37+2 weeks gestation. The case remained undiagnosed throughout pregnancy when after a fairly normal labour a massive haemorrhage occurred. After an unsuccessful effort to control the bleeding conservatively, a total abdominal hysterectomy was carried out. During the operation the diagnosis of cervico-isthmic pregnancy was confirmed, which was in accordance with the pathology report.

Fecundity of infertile women with minimal or mild endometriosis

Abstractu2002Despite significant developments in medical and surgical approaches for treating endometriosis, the optimal therapy has yet to be established. The relationship between prevalence of fecundity and stage of endometriosis according to their management was studied. Of 151 consecutive women with laparoscopy-proved endometriosis stage-1 and 2, operative laparoscopy was performed in 49, medical treatment in 59 and expectant management in 43 cases. During a 24-month period the cumulative pregnancy rates were found to be 36.7%, 30.5% and 20.9% respectively. Survival analysis showed that the probability of carrying the pregnancy beyond 20 weeks were 30.6%, 25.4% and 16.2% respectively. Diagnosis and treatment of early endometriosis is beneficial for the infertile women. Laparoscopic surgery seems to be the milestone of treatment in these cases, increasing the fecundity and involving minimal risk.

Comparative study of RIS with the 131I-OC 125 F(ab′)2 Mab and CT scan prior to second look operation for ovarian cancer

A tumour-associated radiolabelled monoclonal antibody (Mab) 131I-OC 125 F(ab)2 was used to investigate 27 patients 2 weeks after their last chemotherapy regimen and prior to second-look surgery for ovarian cancer. We did compare the radioimmunoscintigraphy (RIS) findings with the CT scan results and the second-look operation data. In 23 out of 27 cases the RIS results correlated with the operation findings, while there were four false-negative results. Computed tomography (CT) scans correlated in 17 out of 23 cases with the operative findings, while there were six false-negative results. We concluded that RIS is more specific in detecting the tumour site within the pelvis, while CT scan is superior in detecting liver metastases.

Fetal blood sampling in twin pregnancies

To evaluate the role of fetal blood sampling for prenatal diagnosis in twin pregnancies.

Predictive values of CA 125 antigen levels and CT scan in second-look procedures for ovarian cancer

23 patients with ovarian cancer were investigated 10 days after their last regimen of chemotherapy by CT scan and CA 125 in comparison with second-look findings. In 17 out of 23 cases the CT scan results correlated with the operative ones. There were 6 false-negative findings but no false-positives. In all cases serum CA 125 levels correlated with the second-look operation. Our data suggest that the upper limit of CA 125, especially for patients, with negative findings, is less than or equal to 20 U/ml which is much lower than that of 35 U/ml, which is generally accepted. They also indicate the value of CA 125 in the detection of persistent ovarian cancer and the value of the CT scan in the detection of liver metastases. According to the above findings we question the value of the second-look operation in certain cases of ovarian cancer.