Prevalence of deep and ovarian endometriosis in early pregnancy: ultrasound diagnostic study

OBJECTIVE

To assess the prevalence and morphological appearance of deep endometriosis and ovarian endometrioma using pelvic ultrasound examination in women attending for an early pregnancy assessment.

METHODS

This was a prospective observational study set within a dedicated early pregnancy unit. The study included 1341 consecutive women who attended for an early pregnancy assessment for reassurance or because of suspected early pregnancy complications. All women underwent a transvaginal scan to assess the location and viability of their pregnancy. In addition, a detailed examination of pelvic organs was carried out to detect the presence of endometriosis and other gynecological abnormalities. Data analysis was performed using logistic regression and multivariable analysis.

RESULTS

The prevalence of deep endometriosis and/or ovarian endometrioma in women attending our early pregnancy unit was 4.9% (95% CI, 3.8-6.2%). In 33/66 (50.0% (95% CI, 37.9-62.1%)) women with endometriosis, this was a new diagnosis that was made during their early pregnancy scan. On multivariable analysis, the presence of endometriosis was strongly associated with a history of subfertility (odds ratio (OR), 3.15 (95% CI, 1.63-6.07)) and presence of a congenital uterine anomaly (OR, 5.69 (95% CI, 2.17-14.9)) and uterine fibroids (OR, 2.37 (95% CI, 1.31-4.28)). Morphological changes typical of decidualization were seen in 11/33 (33.3% (95% CI, 17.2-49.4%)) women with ovarian endometrioma and 18/57 (31.6% (95% CI, 19.5-43.7%)) women with deep endometriotic nodules.

CONCLUSIONS

Deep endometriosis and ovarian endometrioma were present in a significant proportion of women attending for early pregnancy assessment. The prevalence varied depending on a history of subfertility, and therefore is likely to differ significantly among populations, depending on their characteristics. Ultrasound is a useful tool for the detection of endometriosis in early pregnancy and the identification of women who may benefit from specialist antenatal care. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Development of a fertility risk calculator to predict individualized chance of ovarian failure after chemotherapy

PURPOSE

To develop an innovative machine learning (ML) model that predicts personalized risk of primary ovarian insufficiency (POI) after chemotherapy for reproductive-aged women. Currently, individualized prediction of a patient's risk of POI is challenging.

METHODS

Authors of published studies examining POI after gonadotoxic therapy were contacted, and six authors shared their de-identified data (N = 435). A composite outcome for POI was determined for each patient and validated by 3 authors. The primary dataset was partitioned into training and test sets; random forest binary classifiers were trained, and mean prediction scores were computed. Institutional data collected from a cross-sectional survey of cancer survivors (N = 117) was used as another independent validation set.

RESULTS

Our model predicted individualized risk of POI with an accuracy of 88% (area under the ROC 0.87, 95% CI: 0.77-0.96; p < 0.001). Mean prediction scores for patients who developed POI and who did not were 0.60 and 0.38 (t-test p < 0.001), respectively. Highly weighted variables included age, chemotherapy dose, prior treatment, smoking, and baseline diminished ovarian reserve.

CONCLUSION

We developed an ML-based model to estimate personalized risk of POI after chemotherapy. Our web-based calculator will be a user-friendly decision aid for individualizing risk prediction in oncofertility consultations.

Impact of endometriosis on oocyte morphology in IVF-ICSI: retrospective study of a cohort of more than 6000 mature oocytes

BACKGROUND

Infertility associated with endometriosis can be explained by several non-exclusive mechanisms. The oocyte plays a crucial role in determining embryonic competence and this is particularly relevant for in vitro fertilization (IVF) outcomes. According to some authors, the morphology of oocytes could also be a non-invasive marker of oocyte quality. The aim of this study was to evaluate the relationship between endometriosis and oocyte morphology after controlled ovarian stimulation for intracytoplasmic sperm injection (ICSI) on a large oocyte cohort.

METHODS

Single-center comparative retrospective study in the academic In Vitro Fertilization (IVF) unit of the Lille University Hospital. A total of 596 women treated for IVF-ICSI with ejaculated spermatozoa for sperm alterations were included. They were classified as endometriosis (n = 175) or control groups (n = 401). The morphological evaluation of 2,016 mature oocytes from 348 cycles of patients with endometriosis was compared with that of 4,073 mature oocytes from 576 control cycles. The main outcome measures were Average Oocyte Quality Index (AOQI) and metaphase II oocyte morphological scoring system (MOMS). Comparison of groups was carried out by a mixed linear model and by a generalized estimation equation model with a "patient" random effect to consider that a patient might have several attempts.

RESULTS

No difference in AOQI and MOMS scores was found between endometriosis and control women (adjusted p = 0.084 and 0.053, respectively). In case of endometriosis, there were significantly fewer metaphase II oocytes retrieved, embryos obtained, grade 1 embryos and number of cumulative clinical pregnancies compared to controls. In the endometriosis group, endometriosis surgery was associated with a reduced number of mature oocytes retrieved, and the presence of endometrioma(s) was associated with some abnormal oocyte shapes. Nevertheless, no difference concerning the AOQI and MOMS scores was found in these subgroups.

CONCLUSION

Endometriosis does not have a negative impact on oocytes' morphology in IVF-ICSI.

TRIAL REGISTRATION

On December 16, 2019, the Institutional Review Board of the Lille University Hospital gave unrestricted approval for the anonymous use of all patients' clinical, hormonal and ultrasound records (reference DEC20150715-0002).

Decision regret and associated factors following oocyte cryopreservation in patients with diminished ovarian reserve and/or age-related fertility decline

PURPOSE

To evaluate the prevalence and factors associated with decision regret following oocyte cryopreservation (OC) in women with diminished ovarian reserve (DOR) and/or age-related fertility decline (ARFD).

METHODS

A cross-sectional survey study was conducted to five hundred fifty-two women with DOR and/or ARFD who underwent OC between 2014 and 2019 in two private-assisted reproductive units in Istanbul, Turkey. Decision regret was measured using the validated Decision Regret Scale (DRS).

RESULTS

The median and mean DRS scores were 10 (interquartile range: 25) and 13.4 (SD: 13.2, range 0-70), respectively. Eighty-five (52.5%) women reported mild regret and 26 (16%) had moderate to severe regret. Decision regret was inversely associated with the belief in fate regarding childbearing and trust in the efficacy of OC.

CONCLUSIONS

The prevalence of severe decision regret among patients with DOR and/or ARFD undergoing OC is low. Women who had belief in fate and trusted in the efficacy of oocyte cryopreservation had significantly lower decisional regret.

Association of Premenopausal Bilateral Oophorectomy With Restless Legs Syndrome

IMPORTANCE

Restless legs syndrome is a common neurologic disorder that is more prevalent in women than in men, and it has been suggested that female hormones may be involved in the disorder's pathophysiology.

OBJECTIVE

To determine whether women who underwent premenopausal bilateral oophorectomy were at increased risk of restless legs syndrome.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was performed using data from the Mayo Clinic Cohort Study of Oophorectomy and Aging-2 for a population in Olmsted County, Minnesota. There were 1653 women who underwent premenopausal bilateral oophorectomy before the age of 50 years for a benign indication between 1988 and 2007 and 1653 age-matched women (of same age plus or minus 1 year) in a reference group. Follow-up was conducted until the end of the study period (ie, December 31, 2014). Data were analyzed from January to July 2020.

EXPOSURES

Undergoing bilateral oophorectomy, as shown in medical record documentation.

MAIN OUTCOMES AND MEASURES

Diagnosis of restless legs syndrome, as defined using Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria, was recorded.

RESULTS

Among 3306 women, the median (interquartile range) age at baseline was 44.0 (40.0-47.0) years. Women who underwent bilateral oophorectomy, compared with women who did not undergo this procedure, had a greater number of chronic conditions at the index date (eg, 300 women [18.1%] vs 171 women [10.3%] with ≥3 chronic conditions; overall P < .001), were more likely to have obesity (576 women [34.8%] vs 442 women [27.1%]; overall P < .001), and were more likely to have a history of anemia of any type (573 women [34.7%] vs 225 women [13.6%]; P < .001), iron deficiency anemia (347 women [21.0%] vs 135 women [8.2%]; P < .001), and restless legs syndrome before the index date (32 women [1.9%] vs 14 women [0.8%]; P = .008). Women who underwent bilateral oophorectomy prior to natural menopause had a higher risk of restless legs syndrome after the index date compared with women in the reference group (120 diagnoses vs 74 diagnoses), with an adjusted hazard ratio (HR) of 1.44 (95% CI, 1.08-1.92; P = .01). After stratification by indication for the bilateral oophorectomy, there was an increased risk of restless legs syndrome among women without a benign ovarian condition (HR, 1.52; 95% CI, 1.03-2.25; P = .04) but not among women with a benign condition (HR, 1.25; 95% CI, 0.80-1.96; P = .34). Treatment with estrogen therapy through the age of 46 years in women who underwent bilateral oophorectomy at younger ages was not associated with a difference in risk.

CONCLUSIONS AND RELEVANCE

This cohort study found that risk of restless legs syndrome was increased among women who underwent bilateral oophorectomy prior to menopause, especially those without a benign ovarian indication.

Plasma levels of polychlorinated biphenyl, genetic polymorphisms, and the risk of advanced stage endometriosis

Both environmental and genetic factors interact and play a critical role in the pathogenesis of endometriosis. We analyzed the plasma levels of 12 polychlorinated biphenyl (PCB) congeners with genetic polymorphisms of glutathione-S-transferase M1 (GSTM1), glutathione-S-transferase T1 (GSTT1), and aryl hydrocarbon receptor repressor (AhRR) codon 185. Total sum of the 12 congeners was significantly higher in the controls compared with endometriosis group. Women without C/C genotype in AhRR codon 185 had a significantly increased risk of endometriosis compared with those with C/C genotype. Total sum of the 12 congeners was significantly higher in women without C/C genotype compared with those with C/C genotype. Adjusting for age and AhRR codon 185 genotype, there was no significant association between exposure to PCBs and the risk of endometriosis. These findings suggest a possible presence of gene-environment interaction, however, we could not see any clear association between exposure to PCBs and the risk of endometriosis.

Ovarian inguinal hernia

INTRODUCTION

Gynaecological structures such as the ovaries, fallopian tubes, ligaments and uterus are rarely encountered inside a hernial sac. The prevalence of groin hernias containing parts of female genitalia remains unknown. The aim of this review was to summarise the existing evidence on inguinal hernias containing ovaries with or without the other female adnexa.

METHODS

A systematic search was conducted for literature published up to February 2018 using the MEDLINE®, Scopus® and Google Scholar™ databases along with the references of the full-text articles retrieved. Papers on observational studies and case reports concerning women who were diagnosed with an ovarian inguinal hernia (pre or intraoperatively) were considered eligible for inclusion in the review.

RESULTS

Fifteen papers (13 case reports, 2 case series) comprising seventeen patients (mean age 47.9 years) were evaluated. A left-sided hernia was noted in 13 cases (77%) whereas 4 patients had a right-sided hernia. Eight patients underwent preoperative imaging with computed tomography, ultrasonography or both. This was diagnostic in five cases. In 11 patients, hernia contents were repositioned, 2 had a salpingo-oophorectomy and 2 an oophorectomy. Eight patients underwent hernia repair with mesh placement while three had a herniorrhaphy.

CONCLUSIONS

Ovarian inguinal hernias should be considered among the differential diagnoses of a groin mass or swelling. In women of reproductive age, repair of the hernia with the intent to preserve fertility is of critical importance.

Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization

OBJECTIVES

To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications.

STUDY DESIGN

Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges.

RESULTS

We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke).

CONCLUSIONS

Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

Towards complication-free assisted reproduction technology

Assisted reproductive technology (ART) has vastly improved over the last 40 years, from a frequently unsuccessful and complicated procedure requiring hospital admission and routine laparoscopy to a fairly simple outpatient technique with relatively high success rates. However, it is important to stress that ART is not without risk and medical complications may still occur. The incidence of most of these ART-related complications is associated with how women undergo ovarian stimulation. For this reason, physicians should be aware that a carefully thought-out ovarian stimulation protocol and cycle monitoring are of paramount importance to maximise the success of the treatment while avoiding potentially life-threating complications to occur in this frequently otherwise healthy patient population. This review discusses the rationale and evolution of ovarian stimulation strategies over the years and the current developments towards finding a balance between the retrieval of a sufficient number of oocytes and ART-related complication prevention.

Relationships between intensity, duration, cumulative dose, and timing of smoking with age at menopause: A pooled analysis of individual data from 17 observational studies

BACKGROUND

Cigarette smoking is associated with earlier menopause, but the impact of being a former smoker and any dose-response relationships on the degree of smoking and age at menopause have been less clear. If the toxic impact of cigarette smoking on ovarian function is irreversible, we hypothesized that even former smokers might experience earlier menopause, and variations in intensity, duration, cumulative dose, and age at start/quit of smoking might have varying impacts on the risk of experiencing earlier menopause.

METHODS AND FINDINGS

A total of 207,231 and 27,580 postmenopausal women were included in the cross-sectional and prospective analyses, respectively. They were from 17 studies in 7 countries (Australia, Denmark, France, Japan, Sweden, United Kingdom, United States) that contributed data to the International collaboration for a Life course Approach to reproductive health and Chronic disease Events (InterLACE). Information on smoking status, cigarettes smoked per day (intensity), smoking duration, pack-years (cumulative dose), age started, and years since quitting smoking was collected at baseline. We used multinomial logistic regression models to estimate multivariable relative risk ratios (RRRs) and 95% confidence intervals (CIs) for the associations between each smoking measure and categorised age at menopause (<40 (premature), 40-44 (early), 45-49, 50-51 (reference), and ≥52 years). The association with current and former smokers was analysed separately. Sensitivity analyses and two-step meta-analyses were also conducted to test the results. The Bayesian information criterion (BIC) was used to compare the fit of the models of smoking measures. Overall, 1.9% and 7.3% of women experienced premature and early menopause, respectively. Compared with never smokers, current smokers had around twice the risk of experiencing premature (RRR 2.05; 95% CI 1.73-2.44) (p < 0.001) and early menopause (1.80; 1.66-1.95) (p < 0.001). The corresponding RRRs in former smokers were attenuated to 1.13 (1.04-1.23; p = 0.006) and 1.15 (1.05-1.27; p = 0.005). In both current and former smokers, dose-response relationships were observed, i.e., higher intensity, longer duration, higher cumulative dose, earlier age at start smoking, and shorter time since quitting smoking were significantly associated with higher risk of premature and early menopause, as well as earlier menopause at 45-49 years. Duration of smoking was a strong predictor of age at natural menopause. Among current smokers with duration of 15-20 years, the risk was markedly higher for premature (15.58; 11.29-19.86; p < 0.001) and early (6.55; 5.04-8.52; p < 0.001) menopause. Also, current smokers with 11-15 pack-years had over 4-fold (4.35; 2.78-5.92; p < 0.001) and 3-fold (3.01; 2.15-4.21; p < 0.001) risk of premature and early menopause, respectively. Smokers who had quit smoking for more than 10 years had similar risk as never smokers (1.04; 0.98-1.10; p = 0.176). A limitation of the study is the measurement errors that may have arisen due to recall bias.

CONCLUSIONS

The probability of earlier menopause is positively associated with intensity, duration, cumulative dose, and earlier initiation of smoking. Smoking duration is a much stronger predictor of premature and early menopause than others. Our findings highlight the clear benefits for women of early smoking cessation to lower their excess risk of earlier menopause.

Development of endometrioma after cervical conization

The association between cervical conization and subsequent development of endometriosis is uncertain. The objective of this study was to estimate the incidence rate of ovarian endometrioma after cervical conization and to determine factors associated with the development of endometrioma. One hundred forty-two patients who underwent cervical conization at the University of Tokyo Hospital between January 2006 and December 2013 were included in the study. Their medical records were retrospectively studied until April 2015. The incidence rate of postconization endometrioma was calculated. Patients' characteristics (age, parity, preoperative and postoperative diagnosis and observation period) were analyzed. Six patients developed endometrioma after the cervical conization, and the incidence rate of endometrioma among patients who underwent cervical conization was 10.8 per 1000 person-year (95%CI 3.6-20.5). Patients' age, percent of nulliparous, postoperative diagnosis and observation period were not associated with the development of postconization endometrioma. A preoperative diagnosis with invasive cancer (p < 0.05) was significantly associated with the development of postconization endometrioma. The incidence rate of endometrioma among patients who underwent cervical conization in the current study was higher than that reported population.

Ovarian torsion in children: Development of a predictive score

The aim of this study was to identify clinical signs and symptoms of ovarian torsion (OT) in children and to develop a simple predictive score.A chart review of patients with acute adnexal pathologies treated at the University Children's Hospital Basel, Switzerland, between March 2006 and June 2015 was performed. Medical records were screened for demographic and clinical data. These included clinical symptoms, laboratory studies, imaging, and type of treatment. The diagnosis OT was defined as intraoperative visualization of the torsed ovary around its pedicle at least 360 degrees. Variables predictive for OT were identified and the following score for the likelihood of having OT was developed: age (points = number of years) minus 3 points (if vomitus = "yes") and plus 1 point (if "pain duration >12 hours").A total of 80 patients with acute adnexal pathologies were identified. OT was recorded in 17 (21%) cases and ovarian cysts (OC) only in 63 (79%) cases. Patients who presented with OT were significantly younger than patients with OC only (P = .001). Correspondingly, 11 (65%) of the patients with OT had no menarche compared to 3 (5%) patients with OC only (P = .001). Vomiting (P = .001), a shorter pain duration (P = .01), and an elevated C-reactive protein (CRP) (P = .01) were observed significantly more often in patients with OT. The sensitivity of a positive OT score was 0.81 and increased to 1.00 if restricted to girls between 2 to 12 years of age.The presence of vomiting, short duration of abdominal pain, and elevated CRP level have a predictive value for the diagnosis of OT. In these patients, an exploratory laparoscopy should be conducted without delay. The presented OT score appears to be a helpful tool in diagnosing OT in children.

The age-related recurrence of endometrioma after conservative surgery

OBJECTIVE

As endometrioma frequently recurs after conservative surgery, long-term postoperative medical treatment for the prevention of recurrence is necessary. However, it has not been elucidated whether long-term postoperative medical treatment is crucial to all patients until menopause. Thereupon, this study was conducted to evaluate the age-related recurrence patterns after conservative surgery for endometrioma.

STUDY DESIGN

A retrospective cohort study was performed on a total of 420 reproductive-aged women who underwent conservative surgery for endometrioma between January 2000 and December 2010. Ultrasonography was used during the follow-up period to detect endometrioma recurrence. Patients were classified into two groups according to the use of postoperative medications. The first group was observation only, while the second received gonadotropin releasing hormone agonists followed by cyclic oral contraceptives. The cumulative recurrence rate of endometrioma was compared according to the age at surgery (20-29 years, 30-39 years, 40-45 years) within each group. Subgroup analysis was performed according to the age between the two groups.

RESULTS

The median follow-up duration after surgery was 29.0 months (range 6-159 months) for all patients. After adjusting for parity, size and bilaterality of cyst, and stage with American Society for Reproductive Medicine classification of endometriosis which was statistically different, within the group of no treatment, the cumulative recurrence rate in 40-45 years (10.2%) was significantly lower compared with those in 20-29 years (43.3%; hazard ratio (HR)=0.04; 95% confidence interval (CI)=0.01-0.52) and 30-39 years (22.5%; HR=0.19; 95% CI=0.04-0.92). However, there were no differences within the group of postoperative medical treatment. When we compared between the two groups, the cumulative recurrence rate was significantly different in 20-29 years (8.1 vs 43.3%; p<0.001) and 30-39 years (5.4 vs 22.5%; p=0.007), but there was no difference in 40-45 years (4.5 vs 10.2%; p=0.901).

CONCLUSIONS

Our preliminary results demonstrate that the risk of endometrioma recurrence decreases with age. After the age of forty, the recurrence rate does not differ according to the use of postoperative medication. Based on our results, postoperative medical treatment may be individualized according to the patient's age at the time of surgery. Further studies are needed to identify patients who may benefit from postoperative medication.

Association between pregnancy and adnexal torsion: A population-based, matched case-control study

The purpose of this study was to determine the effect of pregnancy on adnexal torsion (AT). We conducted a matched case-control study using the Korean Health Insurance Review and Assessment Service-National Inpatients Sample (HIRA-NIS) from 2009 to 2011. AT patients were defined as women with both a diagnostic code (N835) and a surgical code for AT. The AT patients were randomly matched 1:4 with women without AT by age and year of claim. In total, 545 AT cases and 2180 controls were enrolled from a total of 1,843,451 women. After adjustment for such covariates as age, pregnancy was found to be associated with a lower rate of AT (adjusted odds ratio 0.314, 95% confidence interval [CI] 0.237-0.416, P value <0.01) and ovarian hyperstimulation syndrome was associated with a higher rate of AT (adjusted odds ratio 20.091, 95% CI 3.607-111.908, P value <0.01). We found that pregnancy is a negative risk factor for AT. However, a further study is needed to elucidate the mechanisms underlying these results.

Adolescent polycystic ovary syndrome due to functional ovarian hyperandrogenism persists into adulthood

BACKGROUND

Menstrual irregularity and above-average testosterone levels in adolescence may presage polycystic ovary syndrome (PCOS) in adulthood but persist in only a minority. Prolonged anovulatory cycles in normal adolescents are associated with increased testosterone levels. Thus, questions have been raised about the accuracy of PCOS diagnosed in adolescents.

OBJECTIVE

The purpose of this study was to follow-up hyperandrogenic adolescents with features of PCOS to test the hypothesis that adolescent functional ovarian hyperandrogenism (FOH) persists into adulthood.

STUDY SUBJECTS

A series of adults previously reported to have adolescent PCOS, with most documented to have FOH by GnRH agonist or dexamethasone androgen-suppression test criteria, were recalled.

METHODS

Recall occurred >3 years after the initial diagnosis and at the age of >18.0 years. Respondents underwent examination, baseline androgen evaluation, and an oral glucose tolerance test after discontinuing oral contraceptive therapy.

RESULTS

Of the adolescent hyperandrogenic patients, 68% (15 of 22) were traceable, and 60% of those traced returned for follow-up, including half (n = 8) of the original FOH group. The baseline characteristics of respondents and nonrespondents were not significantly different. Patients with FOH were reevaluated when their mean age was 23.0 years (range, 18.4-29.4 years), gynecologic age was 10.7 years (range, 5.5-18.4 years), and body mass index was 42.3 kg/m(2) (range, 28.3-52.1 kg/m(2); P = .02 vs adolescence). Serum free testosterone was 24 pg/mL (range, 10-38 pg/mL, normal, 3-9 pg/mL; not significant vs adolescence); all were oligomenorrheic. Whereas 3 of 8 had impaired glucose tolerance as adolescents, at follow-up 6 of 8 had developed abnormal glucose tolerance (2 with type 2 diabetes mellitus).

CONCLUSIONS

Adolescents with FOH, which underlies most PCOS, uniformly have persistent hyperandrogenism, and glucose tolerance tends to deteriorate. Testing ovarian androgenic function in hyperandrogenic adolescents may be of prognostic value.

[Management of ovarian endometriomas: intraperitoneal cystectomy versus fenestration and coagulation]

BACKGROUND

Ovarian endometriomas is a common condition among women of reproductive age and represents a major cost in terms of public health. Despite these implications for public health, it remains difficult to arrive at a consensus on the optimal surgical treatment.

AIMS

To study the clinical and paraclinical characteristics of this pathology and to compare two major surgical techniques: the intraperitoneal cystectomy and fenestration -coagulation in terms of recurrence and prognosis for future fertility.

METHODS

A retrospective study of 31 patients who underwent surgical treatment for ovarian endometrioma histologically proved. The study period covers 10 years from January 2000 to December 2009.

RESULTS

Laparoscopy was performed in 27 patients. The endometrioma was located to the left side in 64% of cases. The main strategy performed is intraperitoneal cystectomy in 18 patients (58.8%). In second place we find the fenestration-coagulation. The mean duration of postoperative follow-up is 10.3 months. The recurrence of the cyst and the persistence of pain symptoms were significantly less frequent in the group of patients who underwent intraperitoneal cystectomy.

CONCLUSION

The laparoscopic surgery remains the first line approach in terms of ovarian endometrioma.Cystectomy offers performance equal or superior to the fenestration-coagulation technique, and exposes to fewer recurrences. For these reasons, it should be recommended. The fenestration-coagulation is possible in case the cystectomy is difficult or incomplete.

Ovarian alterations in wild northern pike Esox lucius females

The aim of the present study was to analyse the occurrence of macroscopically visible ovary alterations in 2 populations of northern pike Esox lucius L. originating from lakes in the Mazurian Lake District (NE Poland). The alterations were characterised by ovary tissue that was morphologically malformed, in part or in whole, and contained immature oocytes, i.e. trophoplastic or previtellogenic oocytes instead of vitellogenic oocytes. These alterations were found only in the ovaries, and no morphological alterations of the testes were noted. Macroscopic and histological analyses were carried out in order to classify the observed alterations in the ovaries. Three types of alterations were identified in which morphological malformations as well as histological investigation of the ovaries were considered. An analysis of the size and age of the fish in relation to the occurrence of alterations as well as of the macroscopic and histological nature of the alteration types was made. The data obtained revealed no lake or age dependency of the observed alterations. Based on the results obtained, we suggest that the presence of endocrine disruptors in the environment or/and genetic factors could be responsible for these kinds of gonad anomalies. However, our results did not allow us to determine the aetiology of the alterations.

[Is ovarian function impaired in HIV patients? A clinical pilot study in Burkina Faso]

A lot of studies published on the ten last years showed a decrease of fertility among HIV positive women. The present research aims to see if this decrease is linked to an ovarian failure, using AMH as principal marker of ovarian function. In this pilot study, 54 HIV-positive and 39 HIV-negative women were compared on the basis of their ovarian function, fecundity and possible ovarian failure. A blood sample was taken for hormonal titrations, HIV seropositivity, viral load and CD4 T cell count. An interview explored demographic characteristics, obstetrical and infectious history, and menstrual characteristics. This study was performed in Burkina Faso between January and February 2008. There is no significant difference after adjusting for age of AMH level between the two groups. However, in our study, 5.5% of HIV positive women had a premature menopause, which is a significant variation from the premature menopause rates of the African population, which is 1.4%. In conclusion, this study put the HIV impact on ovarian function into perspective but the high premature menopause rates could suggest an ovarian attack by the virus or the treatment.

High-resolution array-comparative genomic hybridization profiling reveals 20q13.33 alterations associated with ovarian endometriosis

OBJECTIVE

The purpose of this study is to investigate the potential genetic alterations at DNA level in patients with ovarian endometriosis by high-resolution array-based comparative genomic hybridization (array-CGH) analysis.

METHODS

Following the laparoscopic surgical and the post-operative pathological examination, genomic DNA was extracted from endometriomas of 11 women with endometriosis and endometrial tissue of the controls and analyzed by array-CGH. Real-time PCR was used for confirmation the result of array-CGH analysis and detected the DNA copy number variations of the eutopic endometrium from the five patients with the duplication in 20q13.33 region.

RESULTS

All 11 patients with ovarian endometriosis were diagnosed through the laparoscopic surgical and the post-operative pathological examination. We found occurrence of genomic duplication at 20q13.33 chromosomal region with gain of GATA5 and SLCO4A1 genes in 5 of 11 endometriomas from patients.

CONCLUSION

The results of the present study suggest that there was 20q13.33 duplication in women with ovarian endometriosis. This effect might be due to the alterations of GATA5 and SLCO4A1 genes in the gain region, through involving the metabolism of the steroid hormone.

Computed tomographic colonography: colonic and extracolonic findings in an Auckland population

AIM

To determine the nature and prevalence of colonic and extracolonic findings in our population.

METHODS

All patients who underwent computed tomographic colonography (CTC) in the 72-month period from 1 January 2004 to 1 January 2010 were included in the analysis. Demographic data and CTC findings were recorded, according to the CT colonography reporting and data system (CRADS).

RESULTS

There were 2152 consecutive CTC patients; comprising 52.6% female, average age of 60 years; range 19-87. Approximately 84% were symptomatic. CRADS: Colonic findings: 99/2152 patients (4.6%) were C2 category (had 1 or 2 polyps of 6-9 mm). 77/2152 (3.6%) patients were C3 category (>9 mm polyp or >2 polyps of 6-9 mm). 55/2152 (2.5%) were C4 category (possible cancer). This comprises a total potential colonoscopy/surgery referral rate of 10.7%. Extracolonic findings: The majority were normal or clinically unimportant findings. 178/2152 (8.3%) had potentially significant extracolonic findings.

CONCLUSION

Our CTC population is largely symptomatic, and there is a referral rate from CTC to colonoscopy, surgery or surveillance of 10.7%. This is similar to other NZ data and international studies. The 8.3% rate of potentially significant extracolonic findings is at the lower end of the reported range.

Family incidence of endometriosis in first-, second-, and third-degree relatives: case-control study

BACKGROUND

Initial publications examining the hereditary aspects of endometriosis appeared in the early seventies and demonstrated an up to seven-fold risk for endometriosis in first-degree relatives of endometriosis patients. The aim was to evaluate the influence of hereditary aspects on the endometriosis risk in our patient collective.

METHODS

In a retrospective cohort study we evaluated the incidence of endometriosis among first-, second-, and third-degree relatives of endometriosis patients and compare it with its incidence among first-, second-, and third-degree relatives of patients without endometriosis.

RESULT(S)

Eighty patients in whom endometriosis had been confirmed laparoscopically and histologically by biopsy and 60 patients in whom no endometriosis had been found during laparoscopy were given a questionnaire about the presence of symptoms associated with endometriosis and its family incidence. Patients of both the endometriosis and the control group were 37.7 +/- 6.2 and 45.9 +/- 12.0 years of age at the time of the interview, respectively (p < 0.05). Information about the presence of endometriosis was more readily available for relatives of those in the endometriosis group than for those in the control group (325/749 [43.4%] vs. 239/425 [56.2%], p < 0.05). In 5/136 (3.7%) and 8/134 (6.0%) first-degree relatives of endometriosis patients and the control group, respectively, information about the presence of endometriosis was not available (p = 0.554). Endometriosis was found in 8/136 (5.9%) first-degree relatives of patients and in 4/134 (3.0%) first-degree relatives of controls in the real-case analysis (p = 0.248). When comparing endometriosis characteristics between endometriosis patients with and without a history of familial endometriosis, no significant differences were found.

CONCLUSION(S)

There is a trend toward an increased familial incidence of endometriosis. In contrast to the literature, we found a less dramatic increase in familial risk for the development of endometriosis.

[Characteristics and determinants of initiation of premenopausal use of oral progestagens in the French E3N cohort]

OBJECTIVE

To describe the characteristics and determinants of initiation of use of progestagens alone - i.e. without concomitant use of estrogen - among French premenopausal women.

METHODS

Forty-one thousand six hundred and three women from the French E3N cohort were included in our analyses. Prevalence of use was calculated from 1992 to 2005. Determinants of progestagens alone initiation were investigated prospectively from 1992 to 2005, using multivariable Cox proportional hazards models.

RESULTS

Fifty-eight per cent of women who had reached menopause between 1992 and 2005 ever used progestagens alone during their premenopause. Between 1992 and the end of 1990s, the increase in the prevalence of progestagens alone use in our cohort was close to 50%. Initiation of progestagens alone was significantly associated with a high level of education (postgraduate compared to high-school graduate: Hazard ratio [HR]: 1.09 95% confidence interval [CI]: 1.01-1.18), with a normal body mass index (overweight and obese women compared to normal-weight women: HR=0.84, 95% CI: 0.79-0.90 and HR=0.79, 95% CI: 0.69-0.89 respectively), history of gynecological disorders (mastalgia, benign breast disease and benign uterine or ovarian disease [HR=1.38, 95% CI: 1.27-1.49, HR=1.18, 95% CI: 1.13-1.24 and HR=1.60, 95% CI: 1.52-1.68 respectively]) and with recent gynaecological screening (as measured by recently performed mammogram or Pap smear HR=1.11, 95% CI: 1.05-1.17 and HR=1.38, 95% CI: 1.27-1.49 respectively).

CONCLUSION

Since, at least in France, use of progestagens alone at premenopause is common, evaluation of its risks and benefits is of public health importance.

Development of secondary ovarian lesions after hysterectomy without oophorectomy versus unilateral oophorectomy for benign conditions: a retrospective analysis of patients during a nine-year period of observation

PURPOSE

The effect of retained one or both ovaries on the de novo ovarian pathologies required re-operation after hysterectomy due to benign gynecologic conditions were investigated retrospectively. This study was done to determine the occurrence of disease in retained ovaries after hysterectomy.

METHODS

A retrospective analysis of patient charts was performed, comparing the patient reports of women who had secondary ovarian lesions those whose previously undergone total abdominal hysterectomy with unilateral oophorectomy or without oophorectomy in our Department during the nine year period of observation (2000-2009). The study included 1242 women with at least one ovary saved after hysterectomy for benign indications.

RESULTS

De novo ovarian disease was established in 5.1% of patients of hysterectomy without oophorectomy and in 17.6% of patients of at least one ovary saved after hysterectomy for benign indications (p = 0.005). Ovarian pathology requiring re-operation developed in 3.8% of patients who underwent hysterectomy without oophorectomy and in 5.9% of patients who underwent hysterectomy with unilateral oophorectomy (p = 0.536).

CONCLUSION

Women with unilateral oophorectomy at the time of hysterectomy had more than twice the risk of secondary ovarian lesions, compared with those without oophorectomy at hysterectomy. Determinants, such as age, parity and gravidity must be considered when deciding whether or not to perform oophorectomy at hysterectomy.

Correlation of telomere length and telomerase activity with occult ovarian insufficiency

BACKGROUND

Occult ovarian insufficiency is associated with infertility, impaired response to ovarian stimulation, and reduced live birth rates in women treated with assisted reproductive technologies. Although a decline in ovarian follicle number is expected with age, the proximate causes of occult ovarian insufficiency in young women remain poorly understood. Abnormalities in telomere length and telomerase activity in human granulosa cells may serve as molecular markers for this condition.

METHODS

A cross-sectional study was performed. Subjects (37 yr old or less) undergoing in vitro fertilization were classified as cases of occult ovarian insufficiency or controls with mechanical infertility (male or tubal factor). Granulosa cells were acquired at the time of oocyte retrieval to quantify telomere length and telomerase activity.

RESULTS

Fifty-four women were enrolled. Human granulosa cell telomerase activity was demonstrated, and lack of granulosa cell telomerase activity was associated with occult ovarian insufficiency (odds ratio, 11.0; 95% confidence interval, 1.3-495.6; P = 0.02). Telomeres were shorter in women with occult ovarian insufficiency than in controls (relative telomere/single copy gene ratio, 1.88 vs. 3.15; P = 0.039).

CONCLUSIONS

Aberrant telomere homeostasis is associated with occult ovarian insufficiency in young women. This finding is consistent with the presence of telomeric attenuation that has been shown in multiple age-related conditions.

Complications related to ovarian stimulation and oocyte retrieval in 4052 oocyte donor cycles

A retrospective study was conducted in a private infertility centre to evaluate the rate of complications in a large oocyte donation programme. A total of 4052 oocyte retrievals were performed between January 2001 and October 2007. Altogether, 1238 cycles (30.6%) were stimulated with the use of gonadotrophin-releasing hormone (GnRH) agonists and in 2814 cycles (69.4%) the GnRH antagonist protocol was used. The GnRH antagonist treated cycles were triggered with human chorionic gonadotrophin (HCG) or a GnRH agonist in 1295 and 1519 cycles, respectively. Complications related to oocyte retrieval occurred in 17 patients (0.42%) (intra-abdominal bleeding: n = 14, severe pain: n = 2, ovarian torsion: n = 1). Fourteen of these were hospitalized (0.35%) and six donors (0.15%) required surgical intervention. Pelvic infections, injury to pelvic structures or anaesthesiological complications were not observed in this series. Moderate/severe ovarian hyperstimulation syndrome (OHSS) occurred in 22 donors; 11 required hospital admission and 11 were managed on an outpatient basis. All cases were related to HCG triggering (0.87%). Serious complications related to oocyte retrieval occurred at a low rate in healthy young donors. The risk of OHSS can be substantially reduced by specific stimulation protocols, which include GnRH agonist triggering. Prospective oocyte donors should be adequately counselled about the risks related to egg donation.

Patterns of and risk factors for recurrence in women with ovarian endometriomas

OBJECTIVE

To identify risk factors for and the patterns of recurrence of endometrioma and of dysmenorrhea in women with ovarian endometrioma.

METHODS

We evaluated 710 consecutive patients operated on for ovarian endometriomas who were followed up for an average of 22.4 months. Twenty factors were examined to assess their effect on risk of recurrence of endometrioma and of dysmenorrhea using survival analysis. Hazard rate also was estimated to examine recurrence patterns.

RESULTS

For recurrence of endometrioma, the revised American Fertility Society (rAFS) score, younger age at surgery, and previous medical treatment of endometriosis were identified to be risk factors. For recurrence of dysmenorrhea, rAFS score was the only risk factor. For both recurrences, there was a constant hazard rate in the first 28-30 months after surgery, indicating that the recurrence in that period is completely random. After that period, the hazard rate increased dramatically.

CONCLUSION

The total rAFS score, but not rAFS stage, is a risk factor for recurrence of both endometrioma and dysmenorrhea, indicating that the rAFS stage has little prognostic value. The existence of a completely random recurrence period may be a universal phenomenon, with its duration and the magnitude of recurrence risk determined by patient characteristics and quality of care. The second phase of much higher recurrence risk may reflect successful reseeding, reimplantation, and regrowth of ectopic endometrium. Therefore, the identification of risk factors as well as patterns of recurrence should shed better light on possible causes for recurrence, which is now poorly understood.

Retrospective and prospective study of ovarian tumours and tumour-like lesions

Two hundred and thirty three cases of ovarian tumours and tumour like lesions were studied. Of these 233 cases, 96 cases were of ovarian tumours and 137 were tumour like lesions of the ovary. Of the 96 cases of ovarian tumours, 72.9% were benign, 4.1% were borderline and 22.9% were malignant. Histologically surface epithelial tumours were the commonest (48.8%) followed by germ cell tumours (23.9%), sex cord stromal tumours (8.3%) and metastatic tumours (2.0%). Ultrasound guided FNAC done in cases of ovarian tumours showed an accuracy of 100% for malignant lesions and 100% for benign and borderline lesions when compared with histopathological diagnosis. Of the non neoplastic lesions follicular cysts and corpus leuteal cysts were commonest (80.2%). Tuberculosis constituted (2.9%) cases and was the major cause of clinical diagnostic pitfalls for cases in which a clinical diagnosis of ovarian neoplasm was made.

Tuboovarian Abscesses in Postmenopausal Women

OBJECTIVE

To compare the clinical features of tuboovarian abscess (TOA) in pre- and postmenopausal women.

MATERIALS AND METHODS

Between January 1992 and December 2000, all patients with surgically documented TOA at National Taiwan University Hospital were enrolled into this retrospective study. Salient information with respect to the history, current illnesses, risk factors, physical findings, laboratory data, surgeries and postoperative complications was obtained from medical records.

RESULTS

Of 74 patients with TOA, nine were postmenopausal women. Compared with the premenopausal group, postmenopausal patients were significantly more likely to have contributing medical disorders (p < 0.001) and concomitant pelvic malignant tumors (p = 0.037).

CONCLUSION

Thorough investigation for concomitant pelvic malignant tumors and meticulous medical care should be provided for postmenopausal women with TOA.

Recurrence of endometriomas after laparoscopic removal: sonographic and clinical follow-up and indication for second surgery

STUDY OBJECTIVE

This study involved patients who, after laparoscopic surgery, had recurrence of endometriomas detected by sonography. The aim of this study was to evaluate the role of transvaginal sonography (TVS) in the management of recurrent endometriomas and to establish ultrasonographic criteria that would direct the therapy toward additional surgery versus medical or expectant management.

DESIGN

Retrospective analysis of 62 reproductive-age women who showed recurrence of endometriomas on TVS after laparoscopic removal of an ovarian endometrioma by the stripping technique (Canadian Task Force classification II-1).

SETTING

Obstetrics and Gynecology Department, University of Rome Tor Vergata.

PATIENTS

Sixty-two patients with recurrent endometriomas after first-line treatment with laparoscopy.

INTERVENTIONS

Ultrasonographic follow-up and/or second surgery.

MEASUREMENTS AND MAIN RESULTS

Recurrence of an ovarian endometrioma was defined as the presence of ovarian cysts with the typical sonographic criteria of endometriomas and a diameter of more than 10 mm. The clinical and sonographic postoperative follow-up period lasted from 6 to 97 months (median 24.6) after the first procedure. Of 62 patients with recurrent endometriomas, 50 had recurrence on the treated ovary, 7 on the contralateral untreated ovary, and 5 on both the treated and untreated ovaries. Recurrence of endometriomas was associated with symptoms (pain or infertility) in 47 patients (76%), while the remaining 15 (24%) were asymptomatic. Of the 47 symptomatic patients with recurrence detected by TVS, a second procedure was performed in 15. Second surgery in these patients was indicated by the larger size of the recurrent cysts, a poor response to medical treatment, the presence on TVS of pelvic adhesions and nodules of deep endometriosis, and overall progression of the disease. Symptomatic patients who did not undergo a second procedure (32) had smaller recurrent endometriomas. However of the 31 symptomatic patients with large recurrent endometriomas (>3 cm), only 45% had repeat surgery.

CONCLUSION

Recurrent endometriomas, as detected by TVS, can remain asymptomatic and do not necessarily progress in size with or without medical treatment. The decision to reoperate depends less on the endometrioma's size than on symptoms, in particular severe pain, and failure of medical treatment. However such patients are also more likely to have signs of deep nodules and adnexal/bowel adhesions and larger endometriomas on TVS scan, thus predisposing them to require a second procedure.

Determinants of long-term clinically detected recurrence rates of deep, ovarian, and pelvic endometriosis

OBJECTIVE

This study was undertaken to analyze the frequency and the determinants of long-term clinically detectable recurrence rate of deep, ovarian, and pelvic endometriosis.

STUDY DESIGN

The clinical data of 1106 women with first diagnosis of endometriosis observed between 1979 and 2001 were collected.

RESULTS

The 4-year recurrence rate was 24.6%, 17.8%, 30.6% and 23.7%, respectively, for cases of ovarian, pelvic, deep, and ovarian and pelvic endometriosis (P < .05). The recurrence rates decreased in all groups (with the exception of ovarian endometriosis) in the class age 34 years or older, these findings were significant (P < .05). Radicality was associated with lower recurrence rates in all the groups. A pregnancy after diagnosis was associated with a reduced risk of recurrence.

CONCLUSION

The study shows that the recurrence rates of endometriosis were higher in case of deep endometriosis and that the risk factors for recurrence were similar among women with endometriosis at different sites.

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins

OBJECTIVE

To clarify whether the presence of ovarian endometriomas is associated with a reduced responsiveness to ovarian hyperstimulation.

DESIGN

Observational study.

SETTING

University teaching hospital.

PATIENT(S)

Women selected for in vitro fertilization-intracytoplasmic sperm injection (IVF-ICSI) cycles who were found to have unilateral ovarian endometriomas and who did not undergo previous ovarian surgery.

INTERVENTION(S)

Ovarian hyperstimulation using gonadotropins.

MAIN OUTCOME MEASURE(S)

Number of codominant follicles (mean diameter >15 mm) in the affected and in the contralateral intact gonads.

RESULT(S)

Thirty-six patients were enrolled. They underwent 56 IVF-ICSI cycles. The number of codominant follicles in the intact and affected ovaries were 4.0 +/- 2.2 and 3.0 +/- 1.7, respectively (P=.01). This difference corresponded to a mean reduction (95% confidence interval [CI]) of 25% (6%-44%). This deleterious effect was more evident in women with larger cysts, in those with more than one cyst, and in those who were more responsive to ovarian hyperstimulation.

CONCLUSION(S)

The presence of ovarian endometriomas is associated with a reduced responsiveness to gonadotropins.

Absence of follicular phase defect in women with recurrent miscarriage

OBJECTIVE

The study was designed to compare the follicular phase of women with recurrent pregnancy loss and a healthy control group. It is possible that a defective or aberrant follicular phase may be associated with poor oocyte quality leading to a production of an embryo with compromised quality and hence early pregnancy loss.

DESIGN

Prospective case-control study.

SETTING

A tertiary care hospital of Sheffield, UK.

PATIENT(S)

Thirty-four women with recurrent miscarriage and 10 women with no previous history of miscarriage and regular menstrual cycles (control group) were recruited.

INTERVENTION(S)

The characteristics studied included Doppler assessment of blood flow to the follicle and the endometrium. Simultaneously, serum concentrations of biochemical markers such as anti-Müllerian hormone, inhibin B, FSH, LH, and P were compared in the two groups.

MAIN OUTCOME MEASURE(S)

Differences in the two groups.

RESULT(S)

We were unable to detect significant differences in various biochemical and ultrasound measurements in the follicular phase between women with recurrent miscarriage and a control group; however, the expected correlation between ovarian and pituitary hormones, which was observed in the control group, was absent in women with recurrent miscarriage.

CONCLUSION(S)

There may be subtle derangements of the feedback mechanism responsible for regulation of follicle development in this group of women. However, there were no obvious differences in the follicular phase of women with recurrent miscarriage and a healthy control group.

Luteinized unruptured follicle syndrome: incidence and recurrence rate in infertile women with unexplained infertility undergoing intrauterine insemination

BACKGROUND

The objective of this study was to determine the incidence and recurrence rate of luteinized unruptured follicle (LUF) syndrome in women with unexplained infertility undergoing intrauterine insemination (IUI).

METHODS

A total of 167 women with unexplained infertility who underwent 292 cycles of IUI were enrolled in the study. All patients were treated with clomiphene citrate, 50-150 mg/daily from day 5 to 9 of their menstrual cycle. Ultrasound examination to confirm ovulation was performed on the day of IUI (day 0) and every day thereafter for another 3 days (days 1, 2 and 3). A total of 69 women who failed to conceive in the first cycle and 56 women who failed to conceive in the second cycle underwent second and third cycles, respectively.

RESULTS

Of the total 167 patients who underwent first cycle, 42 (25%) had LUF. The incidence of LUF was 56.5% in 69 patients who underwent a second cycle of IUI treatment, of whom 33 patients had LUF in the first cycle with recurrence rate of 78.6%. In 56 patients who underwent 3 consecutive cycles, the incidence of LUF was 58.9% and recurrence rate of 90%. No pregnancies were recorded in patients with LUF during the study period.

CONCLUSION

The incidence and recurrence rate of LUF are significantly increased in subsequent cycles of IUI. In these patients, other options of infertility treatment might be justified.

Hospitalizations for Pelvic Inflammatory Disease and Tuboovarian Abscess

OBJECTIVE

To describe the demographic characteristics of and procedures for patients hospitalized for pelvic inflammatory disease (PID) and tuboovarian abscess in California from 1991 to 2001.

METHODS

We used the International Classification of Diseases, 9th Revision, Clinical Modification, diagnostic and procedural codes in the California Patient Discharge Database and census data to calculate hospitalization rates for PID and tuboovarian abscess by age and race/ethnicity. We estimated the proportion of PID and tuboovarian abscess hospitalizations associated with procedures and estimated average length of hospital stay, readmission rates, and mortality.

RESULTS

From 1991 to 2001, the California hospitalization rate for PID decreased by 61.5% (from 2.6 to 1.0 per 10,000 women). Tuboovarian abscess hospitalization rates declined by 33.3% during the same time period (from 0.6 to 0.4). Pelvic inflammatory disease hospitalization rates were highest among 20-39 year olds compared with other age categories. Black women aged 20-39 had the highest PID hospitalization rates compared with other racial/ethnic groups. The proportion of hospitalizations associated with hysterectomy was lowest for blacks.

CONCLUSION

In California, the hospitalization rate for PID has declined between 1991 and 2001. Black women, 20-39 years of age, had the highest PID hospitalization rates.

LEVEL OF EVIDENCE

III.

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.

Recurrence rate of endometriomas following a laparoscopic cystectomy

BACKGROUND

The objectives were to observe the clinical course of patients who underwent laparoscopic cystectomy (LC) using transvaginal ultrasonography.

METHOD

The definition of "recurrence" was to detect a diffuse, hypoechoic area whose long axis was at least 2 centimeters (cm) on the transvaginal ultrasonogram during the postoperative follow-up period. Using the Cox regression test, we analyzed each patient's background variables, namely, patient's age, the revised American Society of Reproductive Medicine score (r-ASRM score), use of gonadotropin releasing hormone analogues (GnRHa), and pregnancy during the observation period. Next, cyst size and multi-lobularity of each of the 417 cysts were also analyzed as recurrence risk factors per cyst.

RESULTS

The mean postoperative observation period was 21.4+/-16.8 months. During the observation period, 50 (15.9%) out of 315 patients experienced recurrence and 51 (16.2%) out of 315 patients became pregnant. The cumulative recurrence rate per patient was 31.7% over 60 months. Among prognostic factors per patient, age and showed negative and r-ASRM scores positive correlations with cyst recurrence. On the other hand, we did not identify any cyst factors associated with recurrence. The patients who underwent hemilateral LC showed a 5.2% cyst recurrence rate in the ovary that appeared to be normal at the time of the initial surgery.

CONCLUSION

Young age and severe endometriosis appeared to be the factors associated with high recurrence risk. Recurring ovarian endometrimas probably include cysts occurring spontaneously and those recurring from the cyst residues in the lesions where cystectomy has been performed.

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.

Unanticipated findings at bariatric surgery

BACKGROUND

Obesity is associated with an increased prevalence of various intra-abdominal malignancies. There is little consensus as to the screening of the morbidly obese for these malignancies, and there are no guidelines for screening these subjects before bariatric surgery or performing a survey examination during abdominal bariatric surgery.

METHODS

A prospective analysis of 400 consecutive patients (362 women and 38 men) undergoing gastric bypass surgery was performed to identify the incidence of unanticipated intra-abdominal pathology.

RESULTS

All patients underwent abdominal exploration via an upper midline abdominal incision before gastric bypass surgery. Of the 400 patients, abnormalities were found in 31 (8%); 25 of these abnormalities were related to the ovaries. In only three cases (one case each of carcinoid of the appendix, Sertoli-Leydig cell tumor of the ovary, and serous cystadenocarcinoma of the ovary) would there have been a significant difference in the patient's prognosis had the problem been left undiagnosed.

CONCLUSION

It is reasonable to at least evaluate the ovaries in all female patients before proceeding with weight-loss surgery.

Acute appendicitis-like symptoms as initial presentation of ovarian vein thrombosis

Postpartum ovarian vein thrombosis is a rare condition, with an incidence rate being 1/600 deliveries. It most often arises in the right ovarian vein. A 33-year-old patient who had had normal vaginal delivery presented with fever, pain in the right iliac fossa, and leukocytosis on the sixth day after delivery. An antibiotic course was instituted but 3 days later symptoms reappeared. Diagnosis of acute appendicitis was made. At surgery through a McBurney incision, a woody tumoration consistent with ovarian vein thrombosis was found. Anticoagulation therapy with heparin and antibiotics were instituted. Phlebography and color Doppler sonography confirmed the presence of thrombosis of both the common femoral iliac and inferior vena cava. Fribrolysis with urokinase was performed. The patient has remained stable and symptom-free over a 4-year follow-up. Ovarian vein thrombosis typically presents with symptoms suggestive of acute appendicitis, as was the case in our patient. Color Doppler sonography is the favored diagnostic procedure, with CT being a supplementary tool. Surgery is not necessary and treatment consists of anticoagulants and antibiotics. Even though postpartum ovarian vein thrombosis is rare, early recognition of the condition is of paramount importance to institute the adequate treatment and avoid potential serious sequelae.

Association rate between deep peritoneal endometriosis and other forms of the disease: pathogenetic implications

BACKGROUND

It has been suggested recently that deep endometriosis and the other forms of the disease do not share a common pathogenetic mechanism. In this study, we hypothesize that, if this is true, deep peritoneal endometriosis and the other forms should not be significantly associated.

METHODS

Clinical and surgical records of all women who were referred to the Department of Obstetrics and Gynecology, Clinica 'L.Mangiagalli' between January 1995 and June 2002 and who were diagnosed with deep peritoneal pelvic endometriosis at the time of surgery were retrieved. The concomitant presence of superficial endometriotic implants, endometriomas and pelvic adhesions was evaluated. A binomial probability distribution model was used to calculate the 95% confidence interval (95% CI) of the association rates.

RESULTS

Ninety-three women with deep peritoneal endometriosis were identified. The presence of superficial endometriotic implants, endometriomas and pelvic adhesions was documented in 61.3% (95% CI 51.4-71.2%), 50.5% (95% CI 40.3-60.7%) and 74.2% (95% CI 65.3-83.1%) of patients with deep endometriotic nodules, respectively. Overall, deep peritoneal endometriosis was the only form of the disease in only 6.5% (95% CI 2.8-12.3%) of cases. No relevant differences regarding these associations were observed according to the location and the size of the deep endometriotic nodules.

CONCLUSIONS

Results from this study do not support the hypothesis that deep endometriosis should be considered as a distinct entity of the disease.

Increased occurrence of tubo-ovarian abscesses in women with stage III and IV endometriosis

Women who had stage III-IV endometriosis and who were nulliparous or who had delivered no more than two children were much more likely to develop tubo-ovarian abscesses than those without endometriosis.

Comparison of the disease incidences of Finnish Ayrshire and Finnish Black and White dairy cows

Finnish Ayrshire and Finnish Black and White cows were compared regarding the incidences of early and late mastitis, parturient paresis, ketosis, ovarian disorders, metritis and the risk of having a test-day somatic-cell count >200,000 cells ml(-1) at any of the first three monthly test days in lactation. In a retrospective cohort study 101,793 cows from 5844 tie stalls and 11,811 cows from 437 loose-housing systems from all over Finland were followed from calving in 2000 until the end of lactation. The observed incidences of those cows were then analysed using generalised linear mixed models. Finnish Black and White cows had higher incidences of all diseases except ovarian disorders. Although the differences were statistically significant in all models except metritis and early mastitis in loose-housing systems, they were, in our view, only important on the national level (for the breeding organisations), and of little importance for the farmers.

Abdominal surgical emergencies in infants and young children

Surgical emergencies can be missed easily in children, who are not always able to volunteer relevant information. Awareness of the entities discussed in this review might help the EP uncover subtle clues to early diagnoses that might not be initially apparent. Ill-appearing children who have abdominal pain and vomiting should be considered to have ischemic or necrotic bowel until proven otherwise. Possible diagnoses include volvulus, intussusception, and necrotizing enterocolitis. Bilious vomiting, especially in a young infant, should be considered to be an indication of a high bowel obstruction such as midgut volvulus, which warrants immediate surgical consultation. Significant rectal bleeding with abdominal pain can result from intussusception, volvulus, or an inflamed Meckel's diverticulum. Rectal bleeding with unstable vital signs can result from an upper GI bleed (eg, peptic ulcer disease). Painless rectal bleeding can result from a Meckel's diverticulum, polyps, arteriovenous malformation, or a tumor. Examination of the genitalia is imperative, especially in boys, to exclude the possibility of an incarcerated hernia or testicular torsion.

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.

Enlarged ovarian follicles in users of a levonorgestrel-releasing intrauterine system and contraceptive implant

OBJECTIVE

To evaluate the prevalence of enlarged ovarian follicles among users of a 20 micrograms/d levonorgestrel-releasing intrauterine system (Mirena, Leiras Oy, Turku, Finland), of subdermal contraceptive implants releasing Nestorone (Population Council, New York, New York) and of the TCu 380A intrauterine device.

STUDY DESIGN

A cohort study was conducted at the Universidade Estadual de Campinas, Brazil. Three hundred women were enrolled, with 100 participants in each group. Bimanual pelvic examination and vaginal ultrasound were performed during routine gynecologic examinations in women without complaints. In women with enlarged ovarian follicles (> or = 25 mm), estradiol and progesterone levels were assessed weekly until disappearance or reduction of the ovarian image.

RESULTS

Enlarged ovarian follicles were detected in 19%, 10% and 5% of users of the levonorgestrel system, implants and intrauterine device, respectively. Most of the enlarged ovarian images disappeared after 2 weeks of follow-up. Progesterone levels showed that the intrauterine system and TCu 380A IUD (FEI, North Tonawanda, New York) users had presumably ovulated before the first ultrasound examination in contrast to the implant users.

CONCLUSION

Physicians and users should be aware that findings of enlarged ovarian follicles during the use of progestin-only contraceptives are transient and that no medical interventions are necessary.

Prevalence of endometriosis in malignant epithelial ovary tumours

OBJECTIVE

To determine the prevalence of ovarian endometriosis in malignant epithelial ovarian tumours.

STUDY DESIGN

A retrospective analysis of 160 malignant and 23 borderline ovarian tumours during the period 1995-2001.

RESULTS

Fourteen (7.7%) of the tumours contained endometriosis. This affected 22% of the endometrioid and 10.8% of the mixed adenocarcinomas. The mean age of the ovarian endometriosis patients was 43+/-13 range 26-70 years. The incidence in borderline tumours 13% (3/23) was higher than that in ovarian cancer 6.9% (11/160) (P>0.05). Eight (57%) of cases were classified as atypical and six (43%) as typical endometriosis. Nine cases were FIGO (International Federation of Gynaecology and Obstetrics) stage I and 5 stage III.

CONCLUSIONS

Both malignant and borderline ovarian tumours are associated with ovarian endometriosis. In addition, atypical endometriosis was found associated with endometrioid and mixed epithelial ovarian tumours.

Is fertility declining in dairy cattle? A retrospective study in northeastern Spain

The past few decades have seen a dramatic increase in infertility and reproductive disorders associated with a rising milk yield. Herein, we present a 10-year (from 1991 to 2000) retrospective survey of these factors using data from a reproductive management program performed on high-yielding dairy herds in north-east Spain. The data series included 12,711 lactations. The year was divided into warm and cool periods. Data were obtained from cows first inseminated or examined 45-70 days postpartum. The reproductive tract of each animal was examined by palpation per rectum within 43-48 days postpartum. Cows were then weekly examined until insemination or until postpartum Day 70. Cows with a corpus luteum were synchronized for estrus and timed AI. Cows showing natural estrus in the same period were also inseminated. All inseminations were pooled as a single group and inseminated cows were considered cyclic. Inactive ovaries and ovarian cysts were recorded as ovarian disorders. Incomplete uterine involution, endometritis and pyometra were grouped as uterine disorders. Overall cyclicity and pregnancy rates of all AI cows, and cyclicity and pregnancy rates corresponding to the warm period significantly decreased over the 10-year period, yet remained practically constant during the cool period. The incidence of inactive ovaries in the entire population and that corresponding only to cows examined during the warm period significantly increased with time but was similar during the cool period. Ovarian cysts were more frequent during the warm (12.3%) than during the cool (2.4%) period, though these proportions were maintained throughout the study. The incidence of uterine disorders significantly decreased with time and did not differ between cool and warm periods. Milk yield per cow and year increased from 7800 kg in 1991 to 10,200 kg in 2000. Regression analysis revealed that, for all cows and those inseminated or examined in the warm period respectively, each 1000 kg increase in average milk yield was related to decreases of 3.2 and 6% in pregnancy rate, 4.4 and 7.6% in cyclicity, and to increase of 4.6 and 8% in the incidence of inactive ovaries. The rate of uterine disorders decreased 1.1% regardless of season. Our overall results clearly reflect the increased infertility and incidence of reproductive disorders over the study period. This occurred simultaneous to increasing average milk yield. Nevertheless, under our study conditions, a cool environment appears to preserve fertility and reduce the risk of reproductive disorders irrespective of the milk yield. These findings prompt the need to improve management practices by attempting to reduce the effects of factors provoking stress.