Sarah Maheux-Lacroix

Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review with meta-analysis

STUDY QUESTION Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfertile women and how does it perform compared with hysterosalpingography (HSG)? SUMMARY ANSWER sono-HSG is an accurate test for diagnosing tubal occlusion and performs similarly to HSG. WHAT IS KNOWN ALREADY sono-HSG and HSG are both short, well-tolerated outpatient procedures. However, sono-HSG has the advantage over HSG of obviating ionizing radiation and the risk of iodine allergy, being associated with a greater sensitivity and specificity in detecting anomalies of the uterine cavity and permitting concomitant visualization of the ovaries and myometrium. STUDY DESIGN, SIZE, DURATION A systematic review and meta-analysis of studies published in any language before 14 November 2012 were performed. All studies assessing the accuracy of sono-HSG for diagnosing tubal occlusion in a subfertile female population were considered. PARTICIPANTS/MATERIALS, SETTING, METHODS We searched Medline, Embase, Cochrane Library, Web of Science and Biosis as well as related articles, citations and reference lists. Diagnostic studies were eligible if they compared sono-HSG (±HSG) to laparoscopy with chromotubation in women suffering from subfertility. Two authors independently screened for eligibility, extracted data and assessed the quality of included studies. Risk of bias and applicability concerns were investigated according to the Quality Assessment of Diagnostic Accuracy Study (QUADAS-2). Bivariate random-effects models were used to estimate pooled sensitivity and specificity with their 95% confidence intervals (95% CIs), to generate summary receiver operating characteristic curves and to evaluate sources of heterogeneity. MAIN RESULTS AND THE ROLE OF CHANCE Of the 4221 citations identified, 30 studies were eligible. Of the latter, 28 reported results per individual tube and were included in the meta-analysis, representing a total of 1551 women and 2740 tubes. In nine studies, all participants underwent HSG in addition to sono-HSG and laparoscopy, allowing direct comparison of the accuracy of sono-HSG and HSG. Pooled estimates of sensitivity and specificity of sono-HSG were 0.92 (95% CI: 0.82-0.96) and 0.95 (95% CI: 0.90-0.97), respectively. In nine studies (582 women, 1055 tubes), sono-HSG and HSG were both compared with laparoscopy, giving pooled estimates of sensitivity and specificity of 0.95 (95% CI: 0.78-0.99) and 0.93 (95% CI: 0.89-0.96) for sono-HSG, and 0.94 (95% CI: 0.74-0.99) and 0.92 (95% CI: 0.87-0.95) for HSG, respectively. Doppler sonography was associated with significantly greater sensitivity and specificity of sono-HSG compared with its non-use (0.93 and 0.95 versus 0.86 and 0.89, respectively, P = 0.0497). Sensitivity analysis regarding methodological quality of studies was consistent with these findings. We also found no benefit of the commercially available contrast media over saline solution in regard to the diagnostic accuracy of sono-HSG. LIMITATIONS, REASONS FOR CAUTION Methodological quality varied greatly between studies. However, sensitivity analysis, taking methodological quality of studies into account, did not modify the results. This systematic review did not allow the distinction between distal and proximal occlusion. This could be interesting to take into account in further studies, as the performance of the test may differ for each localization. WIDER IMPLICATIONS OF THE FINDINGS Given our findings and the known benefits of sono-HSG over HSG in the context of subfertility, sono-HSG should replace HSG in the initial workup of subfertile couples. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by personal funds. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER This review has been registered at PROSPERO: Registration number #CRD42013003829.

Feasibility and safety of outpatient total laparoscopic hysterectomy.

BACKGROUND AND OBJECTIVE Ambulatory total laparoscopic hysterectomy (TLH) could lead to significant cost savings, but some fear the effects of what could be premature postsurgical discharge. We sought to estimate the feasibility and safety of TLH as an outpatient procedure for benign gynecologic conditions. METHODS We report a prospective, consecutive case series of 128 outpatient TLHs performed for benign gynecologic conditions in a tertiary care center. RESULTS Of the 295 women scheduled for a TLH, 151 (51%) were attempted as an outpatient procedure. A total of 128 women (85%) were actually discharged home the day of their surgery. The most common reasons for admission the same day were urinary retention (19%) and nausea (15%). Indications for hysterectomy were mainly leiomyomas (62%), menorrhagia (24%), and pelvic pain (9%). Endometriosis and adhesions were found in 23% and 25% of the cases, respectively. Mean estimated blood loss was 56 mL and mean uterus weight was 215 g, with the heaviest uterus weighing 841 g. Unplanned consultation and readmission were infrequent, occurring in 3.1% and 0.8% of cases, respectively, in the first 72 hours. At 3 months, unplanned consultation, complication, and readmission had occurred in a similar proportion of inpatient and outpatient TLHs (17.2%, 12.5%, and 4.7% versus 18.1%, 12.7%, and 5.4%, respectively). In a logistic regression model, uterus weight, presence of adhesions or endometriosis, and duration of the operation were not associated with adverse outcomes. CONCLUSION Same-day discharge is a feasible and safe option for carefully selected patients who undergo an uncomplicated TLH, even in the presence of leiomyomas, severe adhesions, or endometriosis.

Cesarean Scar Pregnancies: A Systematic Review of Treatment Options

The objective of this systematic review was to assess the efficacy and safety of treatment options of cesarean scar pregnancies (CSPs). We searched MEDLINE, Embase, and the Cochrane Library from inception to June 2016 as well as reference lists. We included English publications reporting treatment outcomes of at least 10 cases of CSPs. Two authors screened for eligibility, extracted data, and assessed the quality of the included studies. Treatment was considered successful if no subsequent intervention was required after the index treatment. Of the 1257 citations identified, 63 studies were eligible. The overall success rate of systemic methotrexate (MTX) and/or local injection of MTX or potassium chloride was 62%. Dilation and curettage (D&C) was associated with a 28% risk of hemorrhage that dropped to 4% when combined with uterine artery embolization (UAE). Hysteroscopic resection of CSP was unsuccessful in 12% of cases, and inadequate human chorionic gonadotropin decay was the primary indication for additional intervention. Laparoscopic, vaginal, and open excision and repair of the defect were associated with a high success rate (≥96%) and a low risk of hemorrhage (≤4%). Expectant management resulted in a 57% live birth rate, but 63% of women required hysterectomy because of placental implantation abnormalities or second trimester uterine rupture. Most studies were of low methodologic quality, and given the heterogeneity between the studies and groups, statistical comparison of treatment options was deemed inappropriate. In conclusion, the decision to allow the progression of CSPs exposes women to a high risk of life-threatening hemorrhage and hysterectomy. Medical treatment options alone are often insufficient. D&C is a reasonable option in well-selected women or when combined with UAE. The potential benefits of excision and repair of scar defect on further pregnancy outcomes need to be further assessed.

Uterine Artery Embolization Complicated by Uterine Perforation at the Site of Previous Myomectomy

A 46-year-old woman had an unusual complication from uterine myoma embolization by development of extensive necrosis with subsequent uterine perforation at the location of a previous myomectomy. We suggest that a scarred uterus may be a risk factor for uterine fibroid embolization complications, such as uterine necrosis.

Low vs Standard Pressures in Gynecologic Laparoscopy: a Systematic Review.

Background: The optimal intraperitoneal pressure during laparoscopy is not known. Recent literature found benefits of using lower pressures, but the safety of doing abdominal surgery with low peritoneal pressures needs to be assessed. This systematic review compares low with standard pneumoperitoneum during gynecologic laparoscopy. Database: We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing intraperitoneal pressures during gynecologic laparoscopy. Two authors reviewed references and extracted data from included trials. Risk ratios, mean differences, and standard mean differences were calculated and pooled using RevMan5. Of 2251 studies identified, three were included in the systematic review, for a total of 238 patients. We found a statistically significant but modest diminution in postoperative pain of 0.38 standardized unit based on an original 10-point scale (95% confidence interval [CI], –0.67 to –0.08) during the immediate postoperative period when using low intraperitoneal pressure of 8 mm Hg compared with ≥12 mm Hg and of 0.50 (95% CI, –0.80 to –0.21) 24 hours after the surgery. Lower pressures were associated with worse visualization of the surgical field (risk ratio, 10.31; 95% CI, 1.29–82.38). We found no difference between groups over blood loss, duration of surgery, hospital length of stay, or the need for increased pressure. Conclusion: Low intraperitoneal pressures during gynecologic laparoscopy cannot be recommended on the behalf of this review because improvement in pain scores is minimal and visualization of the surgical field is affected. The safety of this intervention as well as cost-effectiveness considerations need to be further studied.

Imaging for Polyps and Leiomyomas in Women With Abnormal Uterine Bleeding: A Systematic Review.

OBJECTIVE: To evaluate the accuracy of saline infusion sonohysterography in comparison with transvaginal ultrasonography for diagnosing polyps and submucosal leiomyomas in women with abnormal uterine bleeding. DATA SOURCES: We searched the databases MEDLINE, EMBASE, CENTRAL, and ClinicalTrials.gov as well as citations and reference lists to the end of November 2015. METHODS OF STUDY SELECTION: Two authors screened 5,347 citations for eligibility. We included randomized controlled trials or prospective cohort studies published in English, assessing the accuracy of saline infusion sonohysterography and transvaginal ultrasonography for diagnosing polyps and submucosal leiomyomas in women with abnormal uterine bleeding. We considered studies using histopathologic specimens obtained at either hysteroscopy or hysterectomy as criterion standard. TABULATION, INTEGRATION, AND RESULTS: Twenty-five studies were eligible. Two authors extracted data and assessed the quality of included studies. Bivariate random-effects models were used to compare the different tests and evaluate sources of heterogeneity. Saline infusion sonohysterography was superior to transvaginal ultrasonography with pooled sensitivity and specificity of 0.92 and 0.89 compared with 0.64 and 0.90, respectively (P<.001). Transvaginal ultrasound sensitivity for diagnosing polyps was particularly low (0.51). Saline infusion sonohysterography was also compared with hysteroscopy in seven studies and had similar sensitivity but inferior specificity (0.93 and 0.83 compared with 0.95 and 0.90, respectively, P=.007). All three procedures were well-tolerated by women. Saline infusion sonohysterography was successfully completed in 95% of women. Technical variations such as the use of balloon catheters were not found to affect diagnostic accuracy. CONCLUSION: Transvaginal ultrasonography lacks sensitivity to be used alone to exclude the presence of polyps and leiomyomas in women with abnormal uterine bleeding. Although less specific than hysteroscopy, saline infusion sonohysterography offers a similar detection rate and permits concomitant visualization of the ovaries and myometrium. Cost, convenience, and tolerability of different imaging techniques require further evaluation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO International prospective register of systematic reviews, http://www.crd.york.ac.uk/PROSPERO, CRD42016034005.

Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis

STUDY QUESTION Can live birth be accurately predicted following surgical resection of moderate-severe (Stage III-IV) endometriosis? SUMMARY ANSWER Live births can accurately be predicted with the endometriosis fertility index (EFI), with adnexal function being the most important factor to predict non-assisted reproductive technology (non-ART) fertility or the requirement for ART (www.endometriosisefi.com). WHAT IS KNOWN ALREADY Fertility prognosis is important to many women with severe endometriosis. Controversy persists regarding optimal post-operative management to achieve pregnancy and the counselling of patients regarding duration of conventional treatments before undergoing ART. The EFI is reported to correlate with expectant management pregnancy rate, although external validation has been performed without specifically addressing fertility in women with moderate and severe endometriosis. STUDY DESIGN, SIZE, DURATION Retrospective cohort study of 279 women from September 2001 to June 2016. PARTICIPANTS/MATERIALS, SETTINGS, METHODS We included women undergoing laparoscopic resection of Stage III-IV endometriosis who attempted pregnancy post-operatively. The EFI was calculated based on detailed operative reports and surgical images. Fertility outcomes were obtained by direct patient contact. Kaplan-Meier model, log rank test and Cox regression were used for analyses. MAIN RESULTS AND THE ROLE OF CHANCE The follow-up rate was 84% with a mean duration of 4.1 years. A total of 147 women (63%) had a live birth following surgery, 94 of them (64%) without ART. The EFI was highly associated with live births (P < 0.001): for women with an EFI of 0-2 the estimated cumulative non-ART live birth rate at five years was 0% and steadily increased up to 91% with an EFI of 9-10, while the proportion of women who attempted ART and had a live birth, steadily increased from 38 to 71% among the same EFI strata (P = 0.1). A low least function score was the most significant predictor of failure (P = 0.003), followed by having had a previous resection (P = 0.019) or incomplete resection (P = 0.028), being older than 40 compared to <35 years of age (P = 0.027), and having leiomyomas (P = 0.037). LIMITATIONS REASONS FOR CAUTION The main limitation of this study is its retrospective design. Imprecision was higher with low EFI due to smaller sample size in this subgroup. Finally, the EFI is somewhat subjective and could be prone to intra- and inter-observer variations. WIDER IMPLICATIONS OF THE FINDINGS Women with a high EFI score have excellent fertility prognosis and may be advised to try to become pregnant with timed intercourse compared to women with a low score, for which prompt referral to ART seems more reasonable. Other prognostic factors can be used to guide the management of women with an intermediate EFI score. These data follow women over many years post-resection and represent longitudinal fertility data rarely demonstrated in such a cohort. The location and impact of lesions on the ability of the adnexa to function seems crucial for the fertility prognosis and should be further investigated. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by the GRACE Research funds. S.M.-L. is the recipient of a Training Award from the Fonds de Recherche Quebec-Sante. D.A. is the primary author of the Endometriosis Fertility Index. All authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER N/A.

Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review protocol

BackgroundHysterosalpingosonography has been suggested as a less invasive alternative to hysterosalpingography for detecting tubal occlusion among subfertile women. We aim to determine the diagnostic accuracy of hysterosalpingosonography and to compare it to hysterosalpingography.Methods/designWe will conduct a systematic review of diagnostic test accuracy. We will search Medline, Embase, Cochrane Library, Web of Science and Biosis, as well as reference lists of included studies and previous related review articles. Diagnostic studies that compared hysterosalpingosonography ± hysterosalpingography to laparoscopy with chromotubation in women suffering from subfertility will be eligible. Two authors will independently screen for inclusion, data extraction, and quality assessment. Methodological quality will be assessed using the Quality Assessment of Diagnostic Accuracy Study 2 tool (QUADAS-2). We will use SAS 9.3 (SAS Institute Inc., Cary, NC, USA, 2011) to program bivariate random-effects models, estimate pooled sensitivity and specificity with 95% confidence intervals and to generate summary receiver operating characteristics curves. We will perform sensitivity analyses to examine the effect of differences in techniques used for hysterosalpingosonography and in methodological quality of studies.DiscussionThis systematic review will help to determine if hysterosalpingosonography is an adequate alternative screening test for diagnosing tubal occlusion. Accuracy of specific sono-HSG techniques may also be identified.Systematic review registrationThis review has been registered at PROSPERO. The registration number is CRD42013003829

Pyomyoma After Uterine Artery Embolization: Laparotomy Avoided by In-Bag Morcellation

We report a case of a pyomyoma in which in-bag morcellation allowed for a total laparoscopic hysterectomy instead of laparotomy, which has been recognized as the standard of care to avoid the spread of infection from morcellation. A 45-year-old multiparous woman presented with sepsis, pelvic pain, and leukocytosis at 1 month after undergoing uterine artery embolization for symptomatic uterine leiomyoma. Pelvic computed tomography scan revealed a 9-cm suspected pyomyoma. A total hysterectomy was performed using a laparoscopic approach with in-bag morcellation. The intervention was successful, and the postoperative course was uneventful. The patient was discharged on postoperative day 1 and was well at 2 months after surgery.

The need for further surgical intervention following primary hysteroscopic morcellation of submucosal leiomyomas in women with abnormal uterine bleeding

Intrauterine hysteroscopic morcellators have been studied as an alternative method for removing submucosal leiomyomas.