Stéphane Gillerot

Neodymium: YAG laser hysteroscopy in large submucous fibroids.

The preoperative use of a potent, subcutaneously injected gonadotropin-releasing hormone agonist (GnRH-a) was evaluated in a series of 60 women with large submucosal fibroids. Myomectomy by hysteroscopy and Nd:YAG laser was easily performed. In 12 cases, the largest portion of the myoma was not inside the uterine cavity and myomectomy was carried by a two-step hysteroscopy. In women who wished to become pregnant, a pregnancy rate of 66% was achieved. Advantages of preoperative use of a GnRH-a are (1) the significant decrease of the fibroid size, (2) a lower fluid absorption, and (3) the restoration of a normal hemoglobin concentration.

Ovarian endometrial cysts: the role of gonadotropin-releasing hormone agonist and/or drainage.

OBJECTIVE To evaluate the role of GnRH agonist (GnRH-a) and/or drainage in the management of large endometriomas. DESIGN This prospective clinical study was conducted in a parallel and randomized design. SETTING Department of Gynecology, Cliniques Universitaires St. Luc, Brussels, Belgium. PATIENTS Eight infertile women with laparoscopically confirmed ovarian endometriotic cysts. After laparoscopic drainage of the ovarian cyst, patients were randomized. Patients in group I (n = 40) received no therapy. Patients in group II (n = 40) received GnRH-a therapy for 12 weeks. A second-look laparoscopy was performed after 12 weeks in each woman. RESULTS After drainage, a quick recurrence of the endometrial cyst was observed in only group I. Indeed, the score and the cyst size were similar to the values observed before the first laparoscopy. In group II, a significant decrease in score and cyst diameter was observed. Ovarian biopsies revealed significant reduction in the stromal vascularization and a significant reduction in the mitotic activity in the group of women treated with GnRH-a. CONCLUSION The quick recurrence of the ovarian cyst after drainage proved that drainage alone is ineffective. Drainage followed by GnRH-a was effective in the reduction of cyst size and the glandular mitotic activity.

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.

Treatment of uterine fibroids with implants of gonadotropin-releasing hormone agonist: assessment by hysterography.

The effect of a potent, subcutaneously injected gonadotropin-releasing hormone (GnRH analog) (Buserelin, Hoechst, Frankfurt/Main West Germany) on the size of uterine leiomyomas and the uterine cavity area was studied in a group of 20 women. In all patients except 1, the uterine cavity area calculated by hysterosalpingography was decreased, with an average decrease of 35% (from 12.0 +/- 5.4 cm2 to 7.8 +/- 3.3 cm2) by 8 weeks of therapy. Significant decrease was observed in the group of women with initial uterine cavity area greater than 10 cm2. In patients with very large submucous fibroids, myomectomy by hysteroscopy and neodymium:YAG laser was easily performed. Rapid relief of symptoms such as menometrorrhagia permits the restoration of a normal hemoglobin concentration. In conclusion, use of GnRH analog represents an adjunct for preoperative reduction of tumor size and may permit surgical treatment by hysteroscopy.

The place of GnRH agonists in the treatment of endometriosis and fibroids by advanced endoscopic techniques

Uterine fibroids and endometriosis are common benign diseases of the female genital tract. Fibroids are commonly associated with infertility and/or menorrhagia, especially if they are submucosal. Endometriosis is diagnosed in more than 35% of patients undergoing laparoscopy for infertility. Both diseases are oestrogen-dependent, and suppression of the secretion of gonadal steroids by administration of a luteinizing hormone-releasing hormone (LHRH) agonist has therefore been proposed as a non-surgical approach to the treatment of these conditions. Because most leiomyomata and endometrial cysts return to near pretreatment size within 4 months after cessation of gonadotrophin hormone-releasing hormone agonist (GnRH agonist) therapyl4, these agents cannot be used as definitive medical therapy but must be considered as an adjuvant for the pre-operative reduction of tumour size.

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.