Yoram Beyth

Extrauterine mislocated IUD: is surgical removal mandatory?

The incidence of intrauterine device perforation is 0.87 per 1000 insertions. An intrauterine device (IUD) may perforate through the uterine wall into the pelvic or abdominal cavity or into adjacent organs. The accepted treatment for displaced IUDs is surgical removal because of the putative risk of adhesion formation or of damage to the intestine or urinary bladder. The purpose of this article is to present three cases of IUD perforation where surgical removal may not have been necessary. In all three cases, the IUD was removed by laparoscopy. No adhesions were found in any of the patients. Criteria for the surgical removal of a displaced IUD, as a result of uterine perforation, should be re-evaluated. Whilst surgical procedures to remove a misplaced IUD must be performed on symptomatic patients, asymptomatic patients, under certain circumstances, may benefit from conservative management.

Primary peritoneal papillary serous adenocarcinoma: Clinical and management aspects

From January 1, 1984 to April 30, 1990, 38 patients were surgically found to have an intraabdominal disease resembling epithelial ovarian cancer. This diagnosis was confirmed in 31 patients; the remaining 7 met the criteria of primary peritoneal papillary serous carcinoma. Five of these were diagnosed retrospectively and two during surgery. The mean age at diagnosis was 61.2 years. Tumor histology revealed papillary serous carcinoma in six and mixed (papillary serous and papillary clear cell carcinoma) in one patient. Optimal debulking was achieved in three of seven cases (42.8%). Cisplatin-based combination chemotherapy was administered to all in the study group. Complete response was obtained in four patients, with one surviving for 76 months. The median survival in these patients was 34.5 months (range 6-76 months). Currently, three patients with complete response are alive with clinically undetectable disease. CA-125 assays were available in three cases and blood levels corroborated the clinically determined status of the disease. Tumor steroid hormone receptor status was determined in one case and revealed low levels of estrogen and progesterone receptors. To the best of our knowledge, the usefulness of CA-125 in the diagnosis, management, follow-up, and determination of tumor steroid hormone receptor status, mixed papillary serous and clear cell subtype histological patterns for primary peritoneal papillary serous carcinoma are first described in this report. It seems that this neoplasm may be treated and followed up as in epithelial ovarian cancer, obtaining long-term survival; however, the biologic behavior and management problems of this relatively new entity deserve further clinical experience.

Exercise training, menstrual irregularities and bone development in children and adolescents.

Weight bearing physical activity plays an important role in bone development. This is particularly important in children and adolescents since bone mineral density reaches about 90% of its peak by the end of the second decade, and because about one quarter of adult bone is accumulated during the two years surrounding the peak bone growth velocity. Recent studies suggested that the exercise-induced increase in bone mineralization is maturity dependent, and that there is a window of opportunity and a critical period for bone response to weight bearing exercise during early puberty and premenarchal years. This supports the idea that increase in physical activity during childhood and adolescence can prevent bone disorders (like osteoporosis) later in life. In contrast, strenuous physical activity may affect the female reproductive system and lead to athletic amenorrhea. The prevalence of athletic amenorrhea is 4-20 times higher than the general population. As a consequence, bone demineralization may develop with increased risk of skeletal fragility, fractures, vertebral instability, and curvature. Menstrual abnormalities in the female athlete result from hypothalamic suppression of the spontaneous pulsatile secretion of gonadotropin releasing hormone. Recent studies suggested that reduced energy availability (increased energy expenditure with inadequate caloric intake) is the main cause of the central suppression of the hypothalamic pituitary-gonadal axis. Therefore, effort should be made to optimize the nutritional state of female athletes, and if not successful, to reduce the training load in order to prevent menstrual abnormalities, and deleterious bone effects in particular during the critical period of rapid bone growth.

Diagnostic value of transvaginal color Doppler flow in ovarian torsion

OBJECTIVEnTo evaluate the role of Doppler flow in the diagnostic process of ovarian torsion.nnnMETHODSnTwenty-two patients who displayed the clinical symptoms of abdominal pain concomitant with an ovarian mass and were scheduled for explorative laparoscopy were enrolled in the study. The cohort was divided into 3 groups: (A) 8 patients with clinical and sonographic evidence of torsion; (B) 8 patients with abdominal pain and sonographic diagnosis of hemorrhagic cyst; and (C) 6 patients with a simple cystic mass who had undergone explorative surgery due to abdominal pain.nnnRESULTSnAfter Doppler flow imaging, Group A displayed no blood flow within the mass, and surgery confirmed the diagnosis of ovarian torsion. Seven of the 8 group B patients showed ovarian vascular flow (RI = 0.472 +/- 0.067). Only 2 of the 6 Group C patients displayed vascular flow (RI = 0.680 +/- 0.129) within an untwisted cyst, confirmed by laparoscopy.nnnCONCLUSIONSnThe combination of Doppler flow imaging with the morphologic assessment improves the diagnostic accuracy of ovarian torsion.

Ovarian volume in postmenopausal women-suggestions to an ovarian sue. nomogram for menopausal age

Background. Transvaginal ultrasonography is an accurate and reliable technique for measuring ovarian size. However, there is no consensus as to the normal ovarian size in postmenopausal women. The purpose of this study was to establish normal values for ovarian volume in postmenopausal age.

Prenatal diagnosis of fetal cerebellar lesions: a case report and review of the literature.

The fetal cerebellar structure, size and consistency are looked at in every system survey. Among the acquired cerebellar events that might change the cerebellar consistency are haemorrhage, infections in utero and neoplasia. Additional fetal malformations, if present, assist in making the final diagnosis. We present a case of an isolated echogenic mass in one of the cerebellar hemispheres along with the differential diagnosis. Copyright

Microhysteroscopy and endometrial biopsy results following failed diagnostic dilatation and curettage in women with postmenopausal bleeding

OBJECTIVE: The aim of this study was twofold: firstly to evaluate and compare the diagnostic precision of the microhysteroscopy (MH) and endometrial biopsy in a group of menopausal women in whom D&C had failed to obtain an adequate endometrial sample, and secondly to quantitate the value of a hysteroscopy in determining endometrial sampling in these patients.

Chromosomal analysis of unfertilized oocytes and morphologically abnormal preimplantation embryos from an in vitro fertilization program.

In vitro fertilization cycles yield a low percentage of pregnancies. Eighty-five to ninety percent of the transferred embryos do not implant, and the abortion rate approaches 30%. Aneuploidy is assumed to be responsible for a major portion of this pregnancy wastage. The purpose of this study was to determine if there was any correlation between morphology and chromosomal content of unfertilized oocytes and rejected embryos. To assess the chromosomal content of oocytes and embryos, we used the method described by Tarkowski in 1966. Sixty oocytes from 28 women, aged between 27 and 41 years, were analyzed. Sixty-seven percent were aneuploid; of these, 23.35% were hyperhaploid, 23.35% were hypohaploid, 8.35% were hyperdiploid, 3.35% were diploid, and 8.35% showed premature chromosome condensation. Of 20 preimplantation embryos analyzed, 80% were aneuploid, 10% were diploid, 5% were haploid, and 5% showed structural anomaly. Correlation was found between maternal age and aneuploidy in oocytes and between morphology and genetic balance in preimplantation embryos.

A simulated patient-based program for training gynecologists in communication with adolescent girls presenting with gynecological problems.

Most gynecologists lack the unique skills required for communication with female adolescent patients and with their parents. Years of clinical experience are required to develop communication skills that would facilitate the confidence of the young patient already during the first visit. Simulation-based medical education at the Israel Center for Medical Simulation (MSR) has become a powerful force in quality-care training for healthcare providers using empirical educational modalities, enabling controlled proactive experiential exposure to both regular and complex scenarios. Among the various MSR programs, for various medical sectors, training programs have been developed to improve the skills of physicians communicating with adolescents, including primary care physicians and school doctors. This paper describes the first reported simulated patient-based MSR training program for gynecologists in communication with adolescents who present with common complaints encountered in gynecology clinics. Twenty gynecologists participated in eight individual simulated scenarios conducted at simulated physicians offices, equipped with audio-visual recording cameras and one-way mirrors for observation. Three physicians experienced in debriefing and in facilitating group discussions led the debriefing sessions, using the video recording of the simulated scenario following the simulation exercises. These discussions focused on communication techniques when facing adolescent patients with or without their parents, hidden agendas disclosed by using systematic physical and psychosocial reviews, the emotional load often associated with clinical problems, and the non-judgmental and supportive approach to adolescent patients. The clear recommendation that emerged from the high satisfaction of the program participants was to expand simulated patient-based programs for gynecologists and to include it as an integrated part of the training curriculum in pediatric and adolescent gynecology.

Is it necessary to perform a prophylactic oophorectomy during hysterectomy

OBJECTIVEnTo evaluate the subsequent pelvic sonographic characteristics as well as the clinical outcome following hysterectomy with and without oophorectomy.nnnSTUDY DESIGNnA prospective study of sonographic evaluation of 164 women, aged 29-72 years, with a history of hysterectomy was performed. Ninety-one patients underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and 73 women had either hysterectomy (abdominal or vaginal) only or hysterectomy with unilateral salpingo-oophorectomy.nnnRESULTSnThe mean time interval between surgery and sonographic evaluation was 4.3 years (range, 1-25 years). Out of the 73 women with left ovaries, 37 (50.7%) were found to have pelvic lesions and four women underwent re-operations following these findings. The histologic finding were cystadenoma, hydrosalpinx with periovarian adhesions and two paraovarian cysts. In comparison, only five of the 91 women (5.5%) following bilateral salpingo-oophorectomy were found to have pelvic lesions (P < 0.0005). None of the women with prophylactic oophorectomy were operated upon following these findings.nnnCONCLUSIONSnIn comparison to patients after total hysterectomy and bilateral salpingo-oophorectomy, women with prior hysterectomy and ovarian preservation are prone to subsequent pelvic lesions. They need to be closely followed with clinical, laboratory and sonographic means, and may undergo reoperations in order to rule out the possibility of neoplasia.