Surgical outcomes of laparoscopic endometriosis surgery: a 6 year experience

OBJECTIVES

The aim of the present study was to review 6 year experience on the surgical outcomes of laparoscopic endometriosis surgery.

METHODS

A cohort study was performed in Shiraz University of Medical Sciences using data from medical records of 1315 cases of patients with endometriosis undergoing laparoscopic surgery with follow-up of 6 to 72 months.

RESULTS

This study concerned a cohort of 1315 patients diagnosed with endometriosis operated between April 2010 and April 2016, 1086 (82.5%) of whom were in stage III and IV; 968 (73.61%) had endometrioma (regardless of having deep infiltrative endometriosis [DIE] or peritoneal involvement) and 347 (26.39%) of patients had either DIE or peritoneal involvement without endometrioma. Regarding the patients, unilateral endometrioma was statistically significant in the left ovary (p = .002). One hundred and thirty-three (10.7%) rectal wall, 7 (0.32%) sigmoid colon, 4 (0.18%) vagina, 125 (5.6%) ureter and 33 (1.52) bladder involvements were detected. Prior to operation, the pain VAS score was 8.23 ± 2.03, which decreased to 4.46 ± 2.47 in 93.07% of patients. Fifty-three patients (6.56%) needed reoperation. Sixty-six (33.1%) infertile women had spontaneous pregnancy and 15 (25%) became pregnant using intrauterine insemination (IUI) or assisted reproductive technique (ART) post-operatively.

CONCLUSION

Surgical treatment of endometriosis seems to be an effective treatment. DIE can be present in the absence of endometrioma. The rate of left endometrioma is higher due to the pressure effect of the sigmoid colon. Nonetheless, if an expert surgeon performs this procedure, not only the rate of post-operative complications, but also the possibility of recurrence would decrease.

Effects of piroxicam administration on pregnancy outcome in intrauterine insemination (IUI) cycles: a randomized clinical trial

BACKGROUND

Uterus contractibility is considered a powerful prognostic factor in predicting the embryo transfer outcome. Moreover, uterine contractions are known to be stimulated by prostaglandins which are produced by cyclooxygenase from arachidonic acid. As such, suppressing the inflammatory response and contractions using anti-inflammatory and relaxant agents is expected to result in increased success rate of embryo transfer and artificial insemination.

OBJECTIVE

To investigate the effect of piroxicam administration on the success rate in intrauterine insemination (IU) cycles in patients presenting with unexplained infertility.

MATERIALS AND METHODS

This randomized, placebo-controlled clinical trial included 260 women with unexplained infertility undergoing IUI cycles. Patients were randomly assigned to receive either piroxicam ten mg/day on days 4-6 after IUI or placebo (control group). The main outcome measures were number of IUI cycles, pregnancy, abortion, and multiple pregnancy rates.

RESULTS

The pregnancy rate was found to be 25 (19.2%) and 16 (12.3%) in piroxicam and control groups, respectively (p = 0.039). Five patients (3.8%) in piroxicam group experienced twin pregnancy whereas only three patients (2.3%) in control group had twin pregnancy (p = 0.361). The pregnancy rate per cycle was also significantly higher in those who received piroxicam as compared to controls (11.16 vs. 6.66; p = 0.021).

CONCLUSION

Administration of piroxicam after IUI is associated with decreased number of cycles, as well as increased pregnancy rate and pregnancy rate per cycle in IUI cycles. However, piroxicam did not have any effect on abortion, multiple pregnancy, and ongoing pregnancy rates.

Decreased ovarian reserve: any new hope?

While diminished ovarian reserve (DOR) predicts decreased ovarian response to stimulation, it does not necessarily foretell about the fecundity cycle. According to Bologna's criteria laid down by the European Society of Human Reproduction and Embryology, old age, abnormal ovarian reserve tests such as antral follicle count (AFC) and anti-mullerian hormone (AMH) as well as prior suboptimal response to stimulation are the main factors representing DOR. Unfavorable response to maximal stimulation on two previous occasions may also represent DOR. Among the ovarian reserve tests, AMH and AFC are the most predictive values for DOR. Factors which may give rise to DOR include environmental factors, autoimmune or metabolic disorders, infections, genetic abnormalities, and iatrogenic causes (such as smoking, chemotherapy, radiation and gynecologic surgeries). Besides, studies have proposed endometriosis as a key contributor to DOR and hence emphasized on its proper management to prevent additional damages leading to compromised fertility. In summary, DOR is found to be a clinical challenge in the practice of fertility care with controversial countermeasures to prevent or treat the condition. Nevertheless, some promising measure such as: oocyte, embryo and tissue cryopreservation, ovarian transplantation, dietary supplementation and the transfer of mitochondria have offered hopes towards ameliorating the burden of DOR. This review attempts to discuss DOR from different perspectives and summarize some existing hopes in clinical practice.

Meningococcal carrier rate before and after hajj pilgrimage: effect of single dose ciprofloxacin on carriage

We determined the carriage rate of Neisseria meningitidis before and after hajj pilgrimage among a group (1) of 674 randomly selected Iranian pilgrims, and the effect of 500 mg of ciprofloxacin given 24 hours before return on the reduction of meningococcal carriers among another group (2) of 123 randomly selected Iranian pilgrims. Throat specimens taken 1 hour before departure on the hajj and immediately on return were cultured. Carriage rates of N. meningitidis in group 1 were 5.2% before and 4.6% after pilgrimage (P = 0.65); 3 new serogroups (Z, Z and A) were identified on return. In group 2, the carriage rate decreased from 8.1% to zero before and after pilgrimage.

Sonohysterography versus transvaginal sonography for screening of patients with abnormal uterine bleeding

OBJECTIVES

To compare the accuracy of saline infusion sonohysterography (SIS) with transvaginal sonography (TVS) for the screening of causes of abnormal uterine bleeding (AUB) in out-patients.

METHODS

81 patients with AUB were studied. All cases who were examined with TVS, were further investigated with SIS using saline as contrast medium, finally hysteroscopy was used as the gold standard.

RESULTS

TVS had sensitivity of 72%, specificity of 92%, positive predictive value of 94% and negative predictive value of 65%, while SIS had sensitivity of 94.1%, specificity of 95%, positive predictive value of 96% and negative predictive value of 90%. TVS had kappa measure of agreement of 0.60 while 0.86 was reported for SIS.

CONCLUSIONS

In this study SIS was more sensitive and specific in diagnosing polyp, myoma and adenomyosis with high positive and negative predictive value. Furthermore, results obtained by SIS demonstrate more agreement with that obtained by hysteroscopy than TVS.

Time of initiation of clomiphene citrate and pregnancy rate in polycystic ovarian syndrome

OBJECTIVE

To investigate whether the timing of clomiphene citrate (CC) administration affects hormonal levels, follicular growth, endometrial thickness, and ovulation and pregnancy rates in women with polycystic ovarian syndrome (PCOS).

METHODS

Of the 78 infertile women with PCOS who participated in this prospective, double-blind, randomized clinical trial, 37 collectively underwent 71 cycles of CC (100 mg/day) on days 1 through 5 of the menstrual cycle (group 1) and 41 collectively underwent 73 cycles of CC at the same concentration on days 5 through 9 (group 2). Hormonal levels, follicular growth, endometrial thickness, and ovulation and pregnancy rates were compared.

RESULTS

The mean number of follicles and the maximum follicular size were greater in group 2. However, ovulation rates were 72.8% in group 1 and 70.8% in group 2 (P=.78), and pregnancy rates were 40.5% in group 1 and 19.5% in group 2 (P=.04).

CONCLUSION

Treatment with CC is associated with higher rates of pregnancy if started early (days 1-5) in the menstrual cycle.

Successful treatment of cervical aplasia using a peritoneal graft

OBJECTIVE

To evaluate the efficacy of a peritoneal graft for the treatment of cervical aplasia.

METHOD

Four patients with cervical aplasia who had a functioning endometrium and hematometra were recruited for this clinical trial. Through an abdominoperineal approach a plastic stent was inserted between the endometrial cavity and the upper part of the vagina; then, a graft of peritoneum was applied over the stent. In the absence of a vagina, grafts of skin or amniotic membrane were also used. The plastic stent was removed after 1 month in 2 patients and after 1 week in the 2 other patients.

RESULT

After more than 1 year of observation the 4 patients had regular menstrual cycles with normal menstruation. Sonographic examinations also showed empty uterine cavities.

CONCLUSION

Traditional gynecology textbooks recommend hysterectomy in cases of cervical aplasia. This report presents a new technique with 2 variations using a peritoneal graft. Although both variations were successful in the treatment of cervical aplasia in 4 women, more trials are needed to determine which one should be developed.

Sonohysterosalpingographic screening for infertile patients

OBJECTIVES

To compare the diagnostic accuracy of hysterosalpingography and sonohysterosalpingography in detecting tubal and uterine abnormalities.

METHODS

In a prospective study for the evaluation of uterine and tubal pathologies, 186 patients with primary and secondary infertility rates (51.6% and 44%, respectively), as well as recurrent abortion rates (3.8%), underwent sonohysterosalpingography. The tubal pathologies, as well as intracavitary and/or structural uterine abnormalities, detected with this procedure were compared with preoperative hysterosalpingography and operative procedures.

RESULTS

With surgical findings as the gold standard, sonohysterosalpingography had a sensitivity of 78.2%, a specificity of 93.1%, a positive predictive value of 82.7%, and a negative predictive value of 91%. For total tubal and uterine pathologies, the findings for the same parameters using HSG were 76.3%, 81.8%, 90.9%, and 59.2%, respectively. Sonohysterosalpingography was more accurate than hysterosalpingography for detecting intrauterine adhesions and various forms of uterine anomalies.

CONCLUSIONS

Sonohysterosalpingography is a safe, easy, accurate, and promising procedure for the detection of female upper genital tract pathologies, especially because it can differentiate specific uterine anomalies.

Effect of clomiphene citrate on endometrium thickness and echogenic patterns

OBJECTIVE

To study the effect of clomiphene citrate (CC) on the thickness and echogenic pattern of the endometrium using vaginal sonography.

METHOD

In this experimental prospective study, CC was given to 31 women with unexplained infertility. Thickness and echo patterns of the endometrium, as well as estradiol (E2) and progesterone (P) levels, were compared in women taking CC and in control patients during both the late proliferative and midsecretory phases of the menstrual cycle.

RESULTS

Endometrial thickness was significantly thinner in women taking CC (P<0.03) than in controls during the late proliferative phase but there was no significant difference during the midsecretory phase. The endometrial echogenic patterns of women taking CC who had conceived revealed endometrial thicknesses of grade III and grade IV on midsecretory days, but these findings were not significantly different from those of women who had not conceived (P=0.3). Serum E2 level was higher in women taking CC than in the controls on both late proliferative and midsecretory days (P<0.05).

CONCLUSION

CC affects endometrium thickness on late proliferative days but not on midsecretory days, and does not alter the echogenic pattern of the endometrium.

Insulin resistance in clomiphene responders and non-responders with polycystic ovarian disease and therapeutic effects of metformin

OBJECTIVES

To evaluate the clinical features, endocrine and metabolic profiles in clomiphene (CC) responders and non-responders with polycystic ovarian disease (PCOD), and to examine the effects of metformin (MTF) on the above parameters of CC resistance.

METHODS

A prospective clinical trial was undertaken at the infertility division of a university teaching hospital. Forty-one CC responders were selected and their hormonal and clinical features were determined. Forty-one CC-resistant PCOD women were also selected and clinical features; metabolic and hormonal profiles before and after treatment with MTF 1500 mg/day for 6-8 weeks were evaluated. Women who failed to conceive were treated by CC while continuing to take MTF.

RESULTS

CC responders had higher insulin levels while non-responders were hyperinsulinemic. Menstrual irregularities improved in 30%. Mean+/-S.D. area under curve of insulin decreased from 297.58+/-191.33 to 206+/-0.1 mIU/ml per min (P=0.005). Only 39.39% ovulated and 24.24% conceived.

CONCLUSION

PCOD is associated with insulin resistance (IR) particularly in CC-resistant women. Insulin resistance and androgen levels are significantly higher in obese patients. MTF therapy improved hyperandrogenemia, IR, and pregnancy rate.

Ovarian size and response to laparoscopic ovarian electro-cauterization in polycystic ovarian disease

OBJECTIVES

To evaluate endocrine and ovulatory changes in polycystic ovarian disease (PCOD) in relation to patients' ovarian size.

METHODS

Three hundred and seventy-one women with clomiphene citrate-resistant PCOD underwent laparoscopic ovarian cauterization [type I or typical with ovarian volume >8 cm(3) or cross-sectional area >10 cm(2) (n=211), type II with normal size ovary (n=160)]. Serum levels of LH, FSH, DHEAS, PRL, and T before and 10 days after ovarian cautery, spontaneous and induced ovulation and pregnancy rates were compared.

RESULTS

Both groups responded to therapy in a similar manner, with a marked decrease in LH, FSH, DHEAS and T levels, with ovulation rates in type I 90.99%, type II 88.75% and pregnancy rates, 73.45% and 71.25%, respectively, with no statistical differences.

CONCLUSIONS

Hormonal changes, ovulation and pregnancy rates were similar in the two types of PCOD, therefore it can be concluded that ovarian size is not a prognostic factor for response of PCOD patients to laparoscopic ovarian electro-cauterization.

Some normative data on the Bender Gestalt test performance of Iranian children

The Bender Gestalt test of visuomotor coordination was applied to a sample of Iranian children (N = 1,600) aged between 6.0 years and 10 years and 11 months attending grades 1 through 5 of 16 public primary schools in Shiraz city, southern Iran. The administration of the test and its scoring followed the standard procedures recommended by Koppitz. The reliability of the test in its new context was investigated through readministering it to a group of 60 children after four weeks, the r being .77. The validity of the test was established by comparing scores of children at different age levels and by correlating test results with marks obtained in two sets of examinations, results of Goodenough Harris Draw-A-Person Test and indices of parental education and occupation. The results are mostly in the expected direction and indicate that the Bender Gestalt test may be used as a simple measure of cognitive-intellectual development in Iran. Observed differences between Iranian norms and those of Koppitz (1963, 1975) for American children are briefly discussed and explained.