Orphan nuclear receptor function in the ovary

Orphan nuclear receptors such as germ cell nuclear factor (GCNF), steroidogenic factor 1 (SF-1) and liver receptor homolog-1 (LRH-1), are emerging as important ovarian factors in regulating female reproduction. Within the ovary, GCNF (NR6A1) expression is restricted to the oocyte, while SF-1 (NR5A1) is expressed only in the somatic cells, such as granulosa, thecal and luteal cells, and interstitial cells. LRH-1 (NR5A2), an orphan receptor closely related to SF-1, is expressed only in the granulosa cells of the follicles and luteal cells within the ovary. Recent studies using conditional knockout strategies to bypass the embryonic lethality of GCNF and SF-1 null mice have uncovered important roles of GCNF and SF-1 in the oocyte and granulosa cells, respectively. In this review, we will summarize the major findings of GCNF and SF-1 in the ovary from the studies of conditional GCNF and SF-1 knockout mice. The potential role of LRH-1 in the ovary is also briefly discussed. Understanding the ovarian functions of these orphan nuclear receptors may lead to the development of new agents for regulation of female fertility and new medicines for the treatment of female idiopathic infertility, premature ovarian failure, polycystic ovarian syndrome and ovarian cancer.

Management of ovarian endometrioma

The optimal conservative treatment for endometriotic cysts is unclear, particularly when treated laparoscopically. We performed a systematic analysis of the published literature on ovarian endometrioma especially focused on comparing laparoscopic cystectomy with laparoscopic drainage and coagulation of the cyst with regard to evaluating advantage and disadvantage of each method. We observed that cystectomy was superior in terms of risk of recurrent symptoms, cyst, reoperation, pregnancy: this was true in both prospective and retrospective studies previously published. Given the evidence available, excision of cyst wall in endometrioma is strongly recommended especially in infertile patients.

Gynecologic abscess: CT-guided percutaneous drainage

A 42-year-old woman with recurrent bilateral endometrial ovarian cystoma presented with fever and pelvic pain caused by a tubo-ovarian abscess (TOA), which was resistant to several varieties of intravenous and oral antibiotics for 2 weeks (Case 1). Computed tomography (CT)-guided diagnostic aspiration for a rapid enlarged right ovarian cystoma through a transabdominal route confirmed that it had developed into a TOA. Subsequent percutaneous abscess drainage (PAD) and irrigation for 3 days were successful. One-year follow-up revealed no recurrence of TOA. A 58-year-old woman with recurrent cervical cancer after external radiation therapy (RT) presented with fever, confusion and tremor caused by pyometra (Case 2). Since transvaginal drainage was impossible due to cervical os obstruction, the patient had undergone CT-guided transabdominal PAD and irrigation for a month. Thereafter, the clinical findings improved and a tracheloplasty was performed to prevent recurrence. CT-guided PAD may be a useful treatment option for gynecologic abscess as a diagnostic aspiration, a temporizing procedure until surgery, or an alternative surgery.

Ovarian Remnant Syndrome

Ovarian remnant syndrome (ORS) refers to a condition occurring in women who have had a bilateral salpingo-oophorectomy (BSO), with or without a hysterectomy, that leaves behind ovarian tissue. This residual ovarian tissue then results in pelvic pain or a pelvic mass. Risk factors associated with incomplete removal of an ovary and subsequent development of ORS include a history of endometriosis, pelvic inflammatory disease, multiple previous surgeries, and pelvic adhesive disease. Patients most frequently present with chronic pelvic pain, pelvic pain associated with a pelvic mass, or an asymptomatic pelvic mass. Definitive criteria for diagnosis of ORS include a history of BSO with histologic documentation of ovarian tissue obtained during subsequent surgical excision. The recommended treatment for ORS is surgical excision by laparotomy or, more recently, laparoscopy. We present the presentation and management of patients with ORS and a review of the published literature.

Nocardial tubo-ovarian abscess in a pregnant woman: A rare case report

Nocardiosis is a rare disease associated with significant morbidity and mortality in immunocompromised patients. We report on a 32-year-old pregnant woman with nocardiosis, which may be the third reported case in which no risk factor for the infection (other than the pregnancy itself) could be found. Pregnancy was complicated by the formation of a tubo-ovarian nocardia abscess, resulting in abortion. Lapartomy with trimethopprim-sulfamethoxazole led to complete cure of the patient at the end of the fifth month. This case emphasizes the difficulty in the diagnosis and treatment of a nocardial infection during pregnancy.

Ovulatory disorders and infertility

Ovulatory disorders represent a major cause of infertility. The World Health Organization classification offers a useful frame for diagnosis and treatment. Polycystic ovary syndrome (PCOS) is the most common cause of oligoovulation and anovulation. Treatment of infertility associated with PCOS has changed in the last decade due to the introduction of new medications. Insulin-sensitizing drugs, such as metformin, became an integral part of treatment. Aromatase inhibitors will most probably replace clomiphene citrate in the future. Women who fail to ovulate or conceive after first-line treatment options are often referred for gonadotropin treatment. Laparoscopic ovarian drilling, which has been evaluated in well-designed trials, may be an alternative to gonadotropins. In vitro fertilization, which yields high pregnancy rates, is the final treatment option when all else fails. Hypogonadotropic anovulation is treated with exogenous gonadotropins, and little has changed in its management. Women with hypergonadotropic hypogonadism should be counseled for adoption or in vitro fertilization with donated oocytes as spontaneous and treatment-associated pregnancy rates are very low.

Abcès primaire de l'ovaire. Diagnostic et approche thérapeutique

Primary ovarian abscess is a rare infection. A new case has led us to carry out a literature review in order to optimize the treatment. Exceptionally isolated, primary ovarian abscess usually belongs to the postoperative complications. Nevertheless, its etiopathogenies are numerous. The symptoms are often poor; therefore the diagnosis is difficult to establish. The curative treatment must associate surgery and antibiotherapy. Even if laparoscopic surgery is the first line treatment in many cases, laparotomy remains the choice procedure. Ultrasonographically-guided evacuation has to be further evaluated. Preventive treatment is of major importance.

Laparoscopic excision of recurrent endometriomas: long-term outcome and comparison with primary surgery

OBJECTIVE

To compare the laparoscopic excision of primary versus recurrent ovarian endometriomas.

DESIGN

Descriptive study.

SETTING

Tertiary referral center for the treatment of endometriosis.

PATIENT(S)

Between 1993 and 2002, 359 consecutive patients: 305 primary surgeries (group A) and 54 reoperations for a recurrent endometrioma in the same ovary of the primary cyst (group B).

INTERVENTION(S)

Laparoscopic stripping of the cyst wall. Follow-up evaluations every 6 months, including clinical and ultrasonographic evaluations and a questionnaire for pain symptoms (mean follow-up time, +/- standard deviation: 35.4 +/- 27.6 months).

MAIN OUTCOME MEASURE(S)

Recurrence of pain symptoms, sonographic recurrence of endometriomas, need for a new medical or surgical treatment, and reproductive outcome.

RESULT(S)

In groups A and B, respectively, the 5-year cumulative rates were not statistically significantly different: pain recurrence 20.5% versus 17.4%; ultrasonographic recurrence 18.9% versus 15.1%; retreatment requirement 19.4% versus 17.3%; and pregnancy 40.8% versus 32.4%. Although the difference was not statistically significant, compared with patients of group A, the women of group B underwent assisted reproduction techniques more frequently (50% vs. 32.2%) and had more irregular menstrual cycles associated with follicle-stimulating hormone levels > or = 14 IU/mL in the early follicular phase (5.5% vs. 1.3%).

CONCLUSION(S)

After laparoscopic excision of recurrent ovarian endometriomas, the recurrence of pain and the reproductive outcome are comparable with those found after primary surgery.

Pasteurella multocida bacteremia and tuboovarian abscess

BACKGROUND

Tuboovarian abscess is commonly associated with sexually transmitted pathogens. We report a tuboovarian abscess caused by a rare pathogen, Pasteurella multocida, which was managed conservatively.

CASE

A 50-year-old sexually inactive woman presented with suprapubic pain and fever. Cat scratches were seen on her hand. Ultrasonography showed a 7.9-cm complex cystic adnexal structure. Her fever persisted despite broad-spectrum parenteral antibiotics. After placement of a transvaginal drain, the patient defervesced, and her pain improved. Both blood cultures and cyst aspirates grew Pasteurella multocida.

CONCLUSION

Tuboovarian abscess secondary to rare pathogens must be considered in the differential diagnosis of acute febrile pelvic illness in a non-sexually active woman. Minimally invasive drainage procedures may avoid surgery in patients failing initial antibiotic therapy.

Ovarian hyperstimulation caused by gonadotroph cell adenoma: a case report and review of the literature

OBJECTIVE

We present a case of spontaneous ovarian hyperstimulation caused by pituitary gonadotroph macroadenoma, and include a review of the literature.

CASE REPORT

A 27-year-old woman presented with irregular menstruation and bilateral multicystic enlargement of the ovaries. Serum estradiol (E(2)) levels were marginally elevated for the follicular phase but within the physiological range. Serum luteinizing hormone (LH) was extremely low, follicle-stimulating hormone (FSH) was normal, and prolactin (PRL) was high. Magnetic resonance imaging disclosed a pituitary macroadenoma. Immunohistochemical examination of the surgically removed adenoma showed intense reactivity for FSH and LH. After the operation, E(2), LH and PRL levels were normalized, the ovaries returned to a normal morphology, and regular menstrual cycles were resumed.

CONCLUSION

A review of the literature showed that ovarian hyperstimulation caused by pituitary gonadotroph adenoma is not always accompanied by elevated FSH levels. High PRL and E(2) and low LH were reported in the majority of the cases, but E(2) may stay within the range observed in normal menstrual cycles.

Impact of ovarian endometrioma on assisted reproduction outcomes

The effects of ovarian endometrioma on fertility outcomes with IVF and embryo transfer have been causally related to poor outcomes. The objective of this meta-analysis was to evaluate the ovarian reserve and ovarian responsiveness to ovarian stimulation and assisted reproduction outcomes in patients with ovarian endometrioma. The odds for clinical pregnancy were not affected significantly in patients with ovarian endometrioma compared with controls, with an overall odds ratio of 1.07 from three studies [95% CI: (0.63, 1.81), P = 0.79]. The overall pregnancy rate was similar with an estimated odds ratio of 1.17 [95% CI: (0.85, 1.60), P = 0.34]. Decreased ovarian responsiveness to ovarian stimulation in patients with ovarian endometrioma may be due to a reduced number of follicles in these patients compared with controls (P = 0.002). Prospective randomized controlled trials are needed to assess whether surgical treatment versus no surgical treatment improves pregnancy outcomes in patients with ovarian endometrioma undergoing assisted reproduction cycles.

A rare presentation of hydatid cyst

Hydatid disease, although known to occur in most body areas, is extremely rare in the female reproductive system. There are different modes of presentation for the disease; however, we report and discuss a case presented with cystic vesicles passing through the vagina, which is considered as a rare presentation for secondary involvement of the uterus and both ovaries. We confirmed diagnosis with radiological examinations and serological tests. We operated on the patient, and studied the excised cysts microscopically. The gynecologist should be aware of hydatid cyst when vaginally passing a grape like vesicle is presented by the patient.

Oocytes in the empty follicle: a controversial syndrome

OBJECTIVE

To assess the prevalence and etiology of the empty follicle syndrome (EFS).

DESIGN

Observational longitudinal study.

SETTING

Tertiary fertility centers.

PATIENT(S)

All patients beginning in vitro fertilization (IVF) treatment from December 2002 to November 2004 were included. Couples undergoing IVF with donor oocytes or participating in an experimental IVF study were excluded from analysis.

INTERVENTION(S)

Identification of EFS cycles. Comparing ovarian hyperstimulation strategy, follicle count, and timing of human chorionic gonadotropin (hCG) for final oocyte maturation of the EFS cycles with normal IVF cycles.

MAIN OUTCOME MEASURE(S)

Number of follicles punctured, number of oocytes recovered, previous and future IVF attempts, and serum hormone levels.

RESULT(S)

Twenty-five of a total of 1,849 patients were identified with an EFS cycle. Reasons for occurrence of EFS cycles were mistiming of hCG for final oocyte maturation, premature ovulation, and poor ovarian response. None of the affected patients had experienced EFS cycles in earlier IVF attempts nor were there any recurrence in subsequent treatments.

CONCLUSION(S)

Accurate timing of induction of final oocyte maturation, properly scheduled ovarian hyperstimulation, instruction of patients and doctors, and full workup for IVF are essential for the successful recovery of oocytes. Occurrence of EFS in IVF can normally be attributed to a failure of at least one of these factors and probably rarely or never occurs otherwise.

Transvaginal ultrasound-guided aspiration for treatment of tubo-ovarian abscess: a study of 302 cases

OBJECTIVE

Our purpose was to evaluate the effectiveness and safety of transvaginal ultrasound-guided aspiration together with antibiotic therapy for treatment of tubo-ovarian abscess.

STUDY DESIGN

A review of women treated with transvaginal ultrasound-guided aspiration for tubo-ovarian abscess at Haukeland University Hospital, Bergen, Norway, between June 1986 and July 2003 was performed. Immediate clinical response and longer-term follow-up results were assessed.

RESULTS

A total of 449 transvaginal aspirations were performed on 302 women. A total of 282 women (93.4%) were successfully treated for transvaginal aspiration of purulent fluid, together with antibiotic therapy. In the other 20 women (6.6%), surgery was performed. The main indications for surgery were diagnostic or therapeutic uncertainty, such as suspected residual tubo-ovarian abscess or pain. No procedure-related complications were diagnosed.

CONCLUSION

Transvaginal ultrasound-guided aspiration combined with antibiotics is an effective and safe treatment regimen for tubo-ovarian abscess. The high success rate indicates that it should be a first-line procedure.

Can ovarian infertility be treated with bone marrow- or ovary-derived germ cells?

A year ago, reproductive biologists and general public were astonished with evidence reported by Johnson et al. in Nature 428:145 that mammalian ovaries possess persisting large germline stem cells, which allegedly enable follicular renewal in adult females. Recently, the same research group declared such view obscure, and reported that mammalian oocytes originate from putative germ cells in bone marrow and are distributed by peripheral blood to the ovaries (Cell 122:303). While neglecting available data on the germ cell origin from the ovarian surface epithelium (OSE) in adult mouse and human females and complexity of follicular renewal in humans, the authors widely extrapolated their observations on formation of allogeneic oocytes after bone marrow (or blood) transplantation in ovaries of adult mice treated with cytostatics to clinical implications in the public media. Yet, the resulting outcome that such allogeneic oocytes may enable the propagation of ovarian cycles is a poor alleviation for the women with ovarian infertility. Women lacking primary follicles, or carrying follicles with low quality eggs persisting in aging ovaries, are not concerned about the lack of menstrual cycles or ovarian steroids, but about virtually no chance of having genetically related children. Johnson et al. also reported that the germ cell formation in bone marrow disappears in ovariectomized mice. Such observation, however, raises solid doubts on the bone marrow origin of oocytes. Since germ cells developing from the OSE cells of adult human ovaries during periodical follicular renewal are known to enter blood vessels in order to enable formation of primary follicles at distant ovarian sites, they also contaminate peripheral blood and hence bone marrow. Better knowledge on the complexity of follicular renewal in humans and exploration of a potential of human OSE cells to produce new oocytes in vitro are essential for novel approaches to the autologous treatment of premature ovarian failure and age induced ovarian infertility.

Endométriome ovarien associé à une infertilité : quelle est la place de l'abstention thérapeutique?

Ovarian endometrioma is not infrequently encountered in infertile patients. Its etiopathogeny, its relations with attributed symptoms and the recommanded treatment to apply, are still debated. Various therapeutic tools are available, such as abstention, ultrasonographically guided aspiration and drainage, and surgery. Each option carries specific advantages and disadvantages. Ultrasonographically guided aspiration bears infectious risks. Among various proposed surgical procedures, cystectomy appears to offer the best performances. Results of IVF are slightly or not altered, neither by an ovarian endometrioma, nor by previous surgery, except in case of iterative surgery or if operated lesions were very severe. Laparoscopic surgery is still the first line treatment in many cases. Abstention can be applied in particular circumstances. Ultrasonographically guided aspiration needs to be further evaluated.

Pericentric inversion of chromosome 2 in a patient with the empty follicle syndrome: Case report

The empty follicle syndrome (EFS) is defined as a lack of retrieved oocytes from follicles, at the time of repeated aspiration and flushing, following ovulation induction. The actual mechanism responsible for the EFS is still unknown. The aim of this study was to offer more information regarding the possible connection of this syndrome with pericentric inversion of chromosome 2. We give a case report of a patient who had multiple failed IVF attempts, due to the absence of oocyte and granulosa cells in the follicular fluid, following oocyte retrieval in both stimulated and natural cycles. Chromosomal analysis showed the presence of a pericentric inversion of chromosome 2: 46,XX,inv(2)(p11q21) in the female partner karyotype, while the male partner had a normal karyotype. Our case showed possible genetic factor influence in the aetiology of EFS.

Tubo-ovarian abscess: diagnosis, medical and surgical management

Tubo-ovarian abscess (TOA), a serious manifestation of pelvic inflammatory disease, has been treated with aggressive surgical therapy. With improvements in antibiotic therapy, laparoscopic surgery and interventional radiological techniques have lessened the need for radical surgical treatment in stable patients.

Tubo-ovarian abscess caused by Vibrio vulnificus

Vibrio vulnificus is a Gram-negative bacterium that causes an aggressive infection with high mortality, especially in patients with liver disease. Wound infections due to V. vulnificus occur via direct contamination of cutaneous tissues and can include the uterus. We report a case of V. vulnificus tubo-ovarian infection from an unusual method of acquisition in the Gulf of Mexico.

Tubo-ovarian abscess mimicking ovarian tumor in a sexually inactive girl

Tubo-ovarian abscess is a serious complication of pelvic inflammatory disease rarely seen in sexually inactive girls. Early diagnosis and treatment are essential to prevent further sequela including infertility, ectopic pregnancy, and chronic pelvic pain. We present a case of 19-year-old sexually inactive girl who presented with abdominal pain and pelvic mass resembling ovarian tumor. Unilateral tubo-ovarian abscess with extensive bowel adhesions was determined at laparotomy. Drainage of the abscess and postoperative antibiotic therapy cured the patient.

Sclerotherapy with 5% tetracycline is a simple alternative to potentially complex surgical treatment of ovarian endometriomas before in vitro fertilization

OBJECTIVE

Conventional treatment of endometriosis involves drainage and removal of the cyst wall, which often results in inadvertent resection of normal ovarian tissue. We previously reported that 12 patients were successfully treated with sclerotherapy using 5% tetracycline. We now report our experience with sclerotherapy before in vitro fertilization (IVF) in an additional 20 patients with ovarian endometriomas.

DESIGN

Prospective, cohort.

SETTING

Private practice.

PATIENT(S)

Women (n = 32) with sonographic evidence of an ovarian endometrioma were offered sclerotherapy in lieu of laparoscopy.

INTERVENTION(S)

Sclerotherapy was performed under conscious sedation and transvaginal ultrasound guidance. An 18-gauge, single-lumen needle was inserted into the endometrioma, and the cyst contents were sequentially aspirated and flushed with sterile saline until the aspirated fluid was clear. Tetracycline (5%) (5-10 mL) was then instilled into the cyst. Saline was injected into the cul-de-sac to dilute any tetracycline that may have leaked. The fluid was then removed. Ultrasound was performed 6 weeks later to assess the efficacy of treatment.

MAIN OUTCOME MEASURE(S)

Resolution of endometrioma and subsequent IVF pregnancy rate.

RESULT(S)

Complete resolution was observed in 24 (75%) of 32 patients, at follow-up exam. Repeat aspiration of watery fluid was required in eight patients before resolution. Repeat treatment with tetracycline was needed in two patients. Only one patient did not ultimately respond. In vitro fertilization was performed in 28 patients; an ongoing gestation resulted in 16 (57%) from the next cycle.

CONCLUSION(S)

Sclerotherapy with 5% tetracycline is a simple, effective (and, in our limited series, safe) alternative to surgical intervention for treatment of endometriomas before IVF.

Endometriosis is not only a gynecologic disease

The efficacy of medical and surgical treatment of endometriosis and pelvic pain is a source of questions and controversies. Complete resolution of endometriosis is not yet possible but therapy has essentially three main objectives: 1) to reduce pain; 2) to increase the possibility of pregnancy; 3) to delay recurrence for as long as possible. In case of moderate and severe endometriosis, operative laparoscopy must be considered as first line treatment. The mean pregnancy rate of 50% reported in the literature following surgery provides scientific proof that operative treatment should first be undertaken to give our patients the best chance of conceiving naturally. In case of rectovaginal adenomyotic nodules, surgery must also be considered as first line therapy, medical therapy being relatively inefficacious. Careful preoperative examination is mandatory (transrectal sonography, magnetic resonance imaging, bowel barium enema or intravenous pyelography) to evaluate potentially severe complications of the disease.

Unilateral ovarian abscess caused by Salmonella

Background: Patients with unilateral ovarian abscesses due to Salmonella are rare.

Case report: A 48-year-old woman with a left ovarian abscess caused by Salmonella group O7 is reported.

Conclusion: In our patient, the ovary may have been seeded hematogenously by salmonellae and may have evolved into a local infection.

Deep Endometriosis: Definition, Pathogenesis, and Clinical Management

"Deep endometriosis" includes rectovaginal lesions as well as infiltrative forms that involve vital structures such as bowel, ureters, and bladder. The available evidence suggests the same pathogenesis for deep infiltrating vesical and rectovaginal endometriosis (i.e., intraperitoneal seeding of regurgitated endometrial cells, which collect and implant in the most dependent portions of the peritoneal cavity and the anterior and posterior cul-de-sac, and trigger an inflammatory process leading to adhesion of contiguous organs with creation of false peritoneal bottoms). According to anatomic, surgical, and pathologic findings, deep endometriotic lesions seem to originate intraperitoneally rather than extraperitoneally. Also the lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomic differences of the left and right hemipelvis. Peritoneal, ovarian, and deep endometriosis may be diverse manifestations of a disease with a single origin (i.e., regurgitated endometrium). Based on different pathogenetic hypotheses, several schemes have been proposed to classify deep endometriosis, but further data are needed to demonstrate their validity and reliability. Drugs induce temporary quiescence of active deep lesions and may be useful in selected circumstances. Progestins should be considered as first-line medical treatment for temporary pain relief. However, in most cases of severely infiltrating disease, surgery is the final solution. Great importance must be given to complete and balanced counseling, as awareness of the real possibilities of different treatments will enhance the patient's collaboration.

Ovarian torsion in children: is oophorectomy necessary?

BACKGROUND

Most pediatric surgeons perform oophorectomy in girls presenting with ovarian torsion in which the ovary appears necrotic. However, the adult gynecology literature suggests that many ovaries can be treated by detorsion alone.

METHODS

All children with ovarian torsion on the gynecology and general surgery services between 1988 and 2002 were reviewed.

RESULTS

There were 36 torsions in 34 children. Seventeen underwent detorsion with or without ovarian cystectomy, and 19 had oophorectomy (mean age 10 years in both groups). Torsion was suspected preoperatively in 94% of the detorsion cases and in 47% of the oophorectomy patients. Median time from presentation to surgery was significantly lower in the detorsion than the oophorectomy group (median 14 v 27 hours; P =.04). Postoperative complications and length of stay were similar between the 2 groups. Despite the ovary being judged intraoperatively as moderately to severely ischemic in 53% of the detorsion cases, follow-up sonogram or ovarian biopsy available in 14 of the 17 cases showed normal ovary with follicular development in each case.

CONCLUSIONS

Simple detorsion was not accompanied by an increase in morbidity, and all patients studied had functioning ovarian tissue on follow-up despite the surgeon's assessment of the degree of ovarian ischemia. Detorsion is the procedure of choice for most cases of ovarian torsion in children.

Tubo-ovarian abscess in older women: is the woman's age a risk factor for failed response to conservative treatment?

OBJECTIVE

To assess retrospectively if there is a trend of change in the epidemiology of tubo-ovarian abscess (TOA) and to define the epidemiologic, clinical and laboratory risk factors associated with failed response to conservative antibiotic therapy.

STUDY DESIGN

The charts of 60 patients, admitted with clinically and sonographically diagnosed TOA between January 1995 and December 2000, were reviewed. On admission, all patients were treated with broad-spectrum antibiotics, and were divided into two groups according to the response to medical treatment. Forty-three patients, responding to antibiotic therapy, constituted group A, whereas 17 patients who did not respond and were further treated by sonographically guided drainage or surgery, were included in group B. The groups were compared with respect to patient characteristics, clinical and sonographic presentation, laboratory findings, duration of hospital stay and recovery rate of different pathogens from the endocervix.

RESULTS

The mean age of patients responding to medical therapy (group A) was significantly lower (39.6 +/- 8.3) than the age of patients who did not respond (group B) (45.3 +/- 6.6) (p = 0.02). The gravidity as well as the percentage of menopausal women were significantly increased in group B (p = 0.03 and p = 0.02, respectively). There was a significantly lower incidence of previous pelvic surgery and past history of PID in group B versus group A (p = 0.02 and p = 0.03, respectively), yet the duration of IUD use was significantly prolonged in group B (p = 0.02). The size of TOA, evaluated clinically and sonographically, was significantly increased in group B compared with group A (p = 0.04 and p = 0.009, respectively). Pelvic peritonitis was observed in 40% of group B patients and in none of group A patients (p = 0.0001). The only laboratory finding differentiating between the two groups was the mean sedimentation rate, being significantly higher in group B than in group A (p = 0.0005). The time interval from admission to afebrile condition as well as the duration of hospitalization were significantly shorter in group A (6.1 +/- 2.3 days) than in group B (10.7 +/- 4.7 days) (p = 0.00003). The incidence of positive culture from the endocervix was significantly higher in group B than in group A (p = 0.007). One hundred percent of patients in group B versus 65.2% of patients in group A were treated with triple agent therapy (p = 0.007).

CONCLUSION

The results of the current study strengthen our previous assumption that there is probably a new trend in the epidemiology of TOA, occurring in older women, who do not present the traditional risk factors for pelvic inflammatory disease and TOA.

The Therapeutic Effects of a Progesterone-Releasing Intravaginal Device (PRID) with Attached Estradiol Capsule on Ovarian Quiescence and Cystic Ovarian Disease in Postpartum Dairy Cows

The objective of this study was to evaluate the effects of a progesterone-releasing intravaginal device (PRID) containing an estradiol benzoate capsule on ovarian dysfunction, including ovarian quiescence, follicular cyst (FC) and luteal cyst or cystic corpus luteum (LC/CCL), in postpartum dairy cows. These ovarian dysfunctions were examined by palpation per rectum relative to plasma progesterone status. The results of clinical examination and hormone assay determined ovarian quiescence in 13 cows, FC in 15 cows and LC/CCL in 7 cows. These cows were treated with PRID for 12 d and then clinical examination was performed. After PRID removal, the proportion of cows exhibiting estrous signs within 7 d and confirmed formation of CL within 7-14 d (markedly effective) were 69.2 % (n=9) for ovarian quiescence, 46.7 % (n=7) for FC, and 28.6 % (2 cows) for LC/CCL. Two cows (15.4 %) in ovarian quiescence, 5 cows (33.3%) with FC and 4 cows (57.1 %) with LC/CCL did not exhibit estrous signs but were recognized as having formed CL within 12-16 d after removal of PRID (effective). These results suggest that treatments of PRID with estradiol benzoate for 12 d have therapeutic efficacy on ovarian dysfunction including ovarian quiescence, FC and LC/CCL in postpartum dairy cows.

Emergent surgical complications of genitourinary infections

The entities described in this article represent processes that arise from, or can be mistaken for, common GU infections. It might be difficult to determine the point at which pyelonephritis develops into EPN or perinephric abscess. It might be equally challenging to distinguish scrotal cellulitis from Fournier's gangrene; however, as most EPs will acknowledge, the mere awareness of these entities in the appropriate clinical circumstances might be enough to prevent a "near-miss" of a surgical emergency.

GnRH analogues, transvaginal ultrasound-guided drainage and intracystic injection of recombinant interleukin-2 in the treatment of endometriosis

We performed a double-blind, randomised controlled trial to evaluate the results of ultrasound-guided aspiration of endometriomas under the effect of GnRH analogues and a possible additional beneficial effect by leaving 600000 IU of recombinant interleukin-2 (rIL-2) in the cysts. Twenty-four women with endometriosis-related symptoms, increased values of CA-125 and transvaginal ultrasonography showing endometriomas >3 cm who were initially sent to us for laparotomy and conservative surgery for endometriosis were included. Main outcome measures were severity of symptoms, size and percentage of echographical reduction of endometriomas and CA-125 levels after 2 menses post-GnRH analogues. Secondary outcome measures were the time until recurrence of abnormal parameters and the need for surgery after treatment. We found moderate clinical results after treatment with drainage plus GnRH analogues and significantly improved results in women having received rIL-2 intracystically. There were no side effects. Two out of 3 previously infertile patients became pregnant after therapy. Though the rates of recurrence of endometriomas >or=3 cm were similar in both groups, the period until recurrence was significantly greater when rIL-2 was used, and the rates of recurrence of symptoms and increased CA-125 values were also significantly lower in patients who received rIL-2. Surgery was finally performed on 10 patients (4 with and 6 without previous rIL-2 treatment) during follow-up (30 +/- 12.7 months). These findings led to the conclusion that transvaginal ultrasound-guided puncture and aspiration of endometriomas under endometrial suppressive therapy with GnRH analogues have some value for endometriosis treatment, improving the clinical manifestations and avoiding some surgical therapies, and that rIL-2 left in the cyst increases these beneficial effects significantly.

Unusual presentations in obstetrics and gynecology

The key to evaluating any patient in the emergency department is to remember to keep an open differential when taking the history and conducting the physical examination. Many of the unusual conditions and complications of gynecologic diseases or procedures discussed in this article can be diagnosed with a careful and complete gynecologic history and examination.

Brucella pelvic tubo-ovarian abscess mimicking a pelvic malignancy

A 57-y-old woman presented with recurrent abdominal and pelvic pain of 6 months' duration with low-grade fever. A computed tomographic scan indicated an ovarian tumor. Laparotomy revealed a pelvic abscess. Her symptoms resolved following surgery and antibiotic therapy. Pathology revealed an extensive inflammatory process. Tissue culture grew Brucella sp. The diagnosis and management of this previously undescribed pelvic tubo-ovarian abscess present a particular challenge.

Management of ovarian endometriomas

The efficiency of medical therapy as a unique treatment for endometrioma has not been demonstrated. Operative laparoscopic management is the 'gold standard' for surgical treatment, and there are no indications to prescribe medical treatment before cystectomy. Post-operative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence of endometriosis after surgical treatment. In case of infertility, the management of endometriomas is controversial. Recurrent ovarian surgery is not recommended.

Pelvic congestion syndrome (pelvic venous incompetence): impact of ovarian and internal iliac vein embolotherapy on menstrual cycle and chronic pelvic pain

PURPOSE

The purpose of this study was to analyze the impact of transcatheter embolotherapy on pain perception and menstrual cycle in women with chronic pelvic pain caused by the presence of ovarian and pelvic varices (ie, women with pelvic congestion syndrome or pelvic venous incompetence).

MATERIALS AND METHODS

From July 1998 to August 2000, 56 patients (mean age, 32.3 y) were treated for chronic pelvic pain. Diagnostic venography of the ovarian veins was followed by transcatheter embolotherapy with a sclerosing agent and coils. A second session was completed to embolize the internal iliac veins in 43 of 56 patients. Visual analog scales (VAS) used to measure pain were administered before embolization and at 3-, 6-, and 12-month follow-up. Questionnaires regarding menstrual history were used as part of the postprocedural analysis.

RESULTS

Percutaneous transcatheter embolotherapy of ovarian and pelvic varices was technically successful in 56 of 56 patients (100%); three patients developed recurrent varices, two of whom were treated with repeat transcatheter embolotherapy. Two patients, early in the experience, had complications in which coils placed in the internal iliac veins embolized to the pulmonary circulation; the coils were snared without clinical sequelae. On the VAS, the mean baseline pain level was 7.8 (range, 3.2-9.8; n = 56); at 3-month follow-up, it was 4.2 (range, 0.0-7.2; n = 56); at 6 months, 3.8 (range, 0.0-6.7; n = 41); and at 12 months, 2.7 (range, 0.0-6.9; n = 32). Differences were significant (P <.001) between baseline pain levels and those at all follow-up intervals (ie, 3, 6, and 12 months). The mean decrease in VAS was 5.1 (65% decrease). The clinical follow-up in this series ranged between 6 and 38 months; the mean was 22.1 months. Regarding the impact of embolization on menstruation, all 24 patients responding to questionnaires indicated no change in menstrual cycle.

CONCLUSION

For patients with ovarian/internal iliac varices, transcatheter embolotherapy provides a nonsurgical treatment option. There is a significant decrease in pain based on VAS without any notable impact on menstrual cycle.

Unilateral massive ovarian edema in a woman with polycystic ovaries

Massive ovarian edema is a rare cause of ovarian enlargement in young women. We report the case of a 20-year-old woman with unilateral massive ovarian edema with findings on ultrasound of an enlarged policystic ovary and pedicle arterial and venous blood flow observed with color and pulsed wave Doppler examination. Massive ovarian edema can be managed conservatively and blood flow in the pedicle of the ovary is detected by color and pulsed wave Doppler examination.

Unilateral massive ovarian edema and polycystic ovaries. A case report

Massive ovarian edema is a rare cause of ovarian enlargement in young women. We report a case in a 20-year-old woman with unilateral edema associated with the ultrasound appearance of polycystic ovary disease. Arterial and venous blood flow in the pedicle was observed with color and pulsed wave Doppler examination. Conservative management was successful.