Salim Bassil

Large ovarian endometriomas

The management of large endometriomas was described in a series of 814 patients. Combined therapy using gonadotrophin-releasing hormone agonist (GnRHa) and carbon dioxide laser laparoscopy was proposed. Drainage and GnRHa for 12 weeks provoked a reduction of the endometrioma size up to 50% of the initial value. After vaporization of the internal wall, a cumulative pregnancy of 51% after 1 year was achieved. A recurrence rate of 8% was observed for a follow-up of 2-11 years. Histological data demonstrated that the epithelium covering the ovary which is the mesothelium can invaginate in the ovarian cortex. Some of the invaginations were seen to be continuous with endometrial tissue, strongly suggesting the metaplasia theory in the pathogenesis of ovarian endometrioma.

An ectopic pregnancy developing in a previous caesarian section scar.

OBJECTIVE To report the diagnosis and management of an ectopic pregnancy (EP) developing in a caesarean section scar. DESIGN Case report. SETTING University medical school. PATIENT(S) A patient with a previous history of two caesarean sections developing an EP. INTERVENTION(S) Methotrexate (MTX) was administered locally under ultrasonographic guidance. MAIN OUTCOME MEASURE(S) Weekly screening of blood hCG levels and yolk sac resorption by endovaginal sonography. RESULT(S) The diagnosis was suspected by vaginal echography and confirmed by magnetic resonance imaging. Local injection of KCl and MTX provoked a progressive resorption of the pregnancy. Human chorionic gonadotropin was undetectable on day 82. CONCLUSION(S) To prevent uterine rupture in cases of an EP developing in a caesarean section scar, a medical approach can be proposed.

Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas

Forty-two patients who underwent a second-look laparoscopy after a unilateral or bilateral intraperitoneal cystectomy for treatment of an ovarian endometrioma of greater than 3 cm were included. At second-look laparoscopy, 92.4% of the adnexae treated for a large endometrioma had no deep ovarian endometriosis. Adhesion de novo formation occurred in 21% of the treated adnexae and in 17% of the contralateral adnexae. Complete or partial recurrence of dense adhesions occurred in 82% of the cases. Laparoscopic cystectomy is effective in treating large endometriomas. However, operative difficulties may be encountered, explaining persistent endometriomas and postoperative adhesions.

Rectovaginal septum adenomyotic nodules: a series of 500 cases.

Objective Laparoscopic procedure with excision of deep fibrotic endometriotic nodules of the rectovaginal septum and histological study of the lesions.

Successful methotrexate treatment of a viable pregnancy within a thin uterine scar

Case report A 37 year old woman presented in her fourth pregnancy eight weeks of gestation with recurrent episodes of vaginal bleeding for seven days. Her first delivery was by a lower segment transverse caesarean section at 33 weeks of gestation due to pre-eclampsia. Her second and third pregnancies ended by a normal vaginal delivery. On admission her pulse and blood pressure were normal. Pelvic examination revealed moderate bleeding from the cervical canal; the cervix was long and closed. The size of the uterus was consistent with her dates. Transvaginal ultrasound demonstrated a live fetus with a crown-rump length of 19 mm equivalent to her menstrual dates. The gestational sac was 25 mm diameter which was located in the anterior wall of the uterus, just above the internal 0s. Only 4 mm thickness separated the sac from the urinary bladder, and the sac was located between two normal segments of the anterior uterine wall (Fig. 1). Based upon the ultrasound findings, a diagnosis of pregnancy in a very thin uterine scar was made. Following discussion, it was decided to terminate her pregnancy with methotrexate. A single dose of 80 mg (50 mg/m2) intramuscular methotrexate was given. Daily ultrasonography revealed loss of fetal heart beats three days following the injection. No adverse side effects were observed. Three days after the injection, the plasma level of the p subunit of human chorionic gonadotropin (p hCG) was 12,100 mIU/mL; it decreased to 1270, 107 and 20 mIU/mL after two, four and eight weeks, respectively. Despite the declining values of plasma p hCG levels, the patient had prolonged mild vaginal bloody discharge. Ultrasonography showed the same gestational sac containing amorphous tissue debris. Nine weeks after the methotrexate injection 10 ml of straw-like fluid was aspirated from the gestational sac by a transvaginal ultrasound guided needle, without any complications. Three months later transvaginal ultrasound showed complete disappearance of the gestational sac and normal uterine anatomy. Eight months after the

Uterine vascularity during stimulation and its correlation with implantation in in-vitro fertilization

The changes in uterine artery blood flow in women undergoing in-vitro fertilization cycles were studied throughout stimulation after gonadotrophin-releasing hormone (GnRH) desensitization. The data obtained showed that the uterine vascularity was related to hormonal changes. The GnRH agonist effect was seen only after the third week of administration, and the uterine perfusion was significantly (P = 0.002) improved by the oestradiol secretion. Human chorionic gonadotrophins increased the resistance index (RI) significantly (P = 0.0001) for a period of 48 h. Then the progesterone secretion modified the curve with a significant improvement in the uterine blood flow (P = 0.03). Comparison of the RI value 2 days before human menopausal gonadotrophin (HMG) commencement, in patients with and without pregnancy, showed a higher RI in patients who did not conceive but no difference was observed on the day of embryo transfer. The pregnancy rates were similar whatever the range of the RI observed. The data available so far suggest that haemodynamic parameters alone, detected by Doppler sonography, do not provide full information on endometrial receptivity on the day of embryo transfer. A resistance index > 0.79 before HMG commencement seems to indicate poor uterine vascularity and may necessitate an increase in the HMG doses to prevent endometrial immaturity.

Morphometric, immunohistological and three-dimensional evaluation of the endometrium of menopausal women treated by oestrogen and Crinone, a new slow-release vaginal progesterone.

Recently advanced computerized technology was applied to the investigation of morphometric, immunohistological and three-dimensional changes of the endometrial mucosa in order to evaluate quantitatively the effects of three doses of a new slow-release vaginal progesterone on the endometrium in post-menopausal women. A total of 20 menopausal women, deprived of ovarian function, were given oestrogen for 12 days and a combined therapy of oestrogen (administered orally) and progesterone for another 12 day period. Progesterone was administered vaginally through a new gel (Crinone) utilizing a bioadhesive, biocompatible polymer as a base to achieve a sustained release effect. An endometrial biopsy was taken before treatment, after oestrogen-only treatment and after the oestro-progestogen therapy. Before treatment, all the patients exhibited an atrophic endometrium. After oestrogen-only treatment, typical proliferative changes occurred: an increase in the endometrium thickness, an increase in the mitotic index, numerous cylinder-like glands and no coiled glands, and high concentrations of oestrogen receptors (ER) and progesterone receptors (PR). After the oestro-progestogen therapy, whatever the dose of progesterone given, a secretory transformation of the endometrial mucosa occurred, mitotic activity decreased significantly, more ramified and coiled glands were observed, and a decrease in PR content was noted in epithelial and stromal nuclei, and a decrease in PR content was also observed in epithelial nuclei but not in stromal nuclei. Accurate new techniques of image analysis have shown that crinone therapy could eliminate the proliferative effects of oestrogen treatment in post-menopausal women, despite doses as low as 45 mg of progesterone administered vaginally every other day. The results suggest that the sustained release effects of Crinone are clinically relevant.

In vitro fertilization outcome according to age and follicle-stimulating hormone levels on cycle day 3.

Purpose:In a retrospective study, the prognostic factors of in vitro fertilization outcome were studied in women of 39 years of age or older, with an elevated cycle day 3 follicle-stimulating hormone (FSH) level.Methods:Ovarian stimulation was achieved with a combination of gonadotropin-releasing hormone agonist/human menopausal gonadotropin in a short protocol. All patients underwent FSH dosage on cycle day 3 prior to stimulation. The pregnancy rate was studied according to age, FSH levels, and stimulation parameters.Results:There was a negative correlation between day 3 FSH levels and the number of ovocytes retrieved. Cycles canceled because of the absence of ovarian response had a significantly higher mean FSH value (18.2 mlU/ml) than cycles ending in ovocyte retrieval (14.6 mlU/ml). Patients with three or more growing follicles during stimulation achieved a significantly higher pregnancy rate per egg retrieval (16%) compared to patients with fewer than three growing follicles (6%). Eighty percent of those pregnancies were obtained during the first two IVF cycles. Even with an elevated FSH level, some patients developed three or more follicles after stimulation. In such cases, the number of embryos available for transfer was the only significant limiting factor to achieving pregnancy.Conclusions:As our results suggest, there is a discrepancy between biological and chronological ovarian age. In patients with an elevated cycle day 3 FSH level and over 40 years of age, alternatives to fertility treatments (ovum donation, adoption, or no treatment) should not be considered as first choices. Indeed, even with elevated FSH levels, a 16% pregnancy rate per egg retrieval may be obtained if three or more growing follicles can be seen during ovarian stimulation. However, in the presence of fewer than three growing follicles during ovarian stimulation, the patient should be informed about the discouraging prognosis of the running cycle.

A unilateral hydrothorax as the only manifestation of ovarian hyperstimulation syndrome: a case report.

OBJECTIVE To describe a rare case of unilateral hydrothorax occurrence after ovarian stimulation for IVF. DESIGN Case report. SETTING A university hospital. PATIENT(S) A 39-year-old female suffering from primary infertility due to a severe male factor. INTERVENTION(S) Thoracocentesis with IV albumin administration for correction of a concomitant hypoalbuminemia. MAIN OUTCOME MEASURE(S) Laboratory values of hematologic measures and electrolytes, screening of the thoracic fluid aspirated for viral and bacterial infections, resolution of pleural effusion after the second thoracocentesis as determined by chest roentgenogram. RESULT(S) Treatment of this manifestation of the ovarian hyperstimulation syndrome (OHSS) by thoracocentesis with albumin perfusion. CONCLUSION(S) This report describes a very rare case of thoracic complication after ovarian stimulation. It demonstrates that pleural effusion may be the only manifestation of the OHSS and implies a careful management of patients with pulmonary complaints after treatment with exogenous gonadotropins.

Expansive benign lesions: treatment by laser

Submucous fibroids, polyps and dysfunctional bleeding are responsible for meno-metrorrhagia in women over 40 years of age. The authors describe the technique of hysteroscopic myomectomy and endometrial ablation using the Nd-YAG laser and the advantages of the preoperative use of GnRH agonist therapy. They report their results in a series of 746 patients treated for meno-metrorrhagia (366 cases of myomectomy and 380 cases of endometrial ablation).