Ethanol endometrioma sclerotherapy: safety through 8 years of experience

STUDY QUESTION

What are the complications of transvaginal ethanol sclerotherapy for the treatment of endometriomas?

SUMMARY ANSWER

Sclerotherapy is a reliable, minimally invasive method applicable in outpatient procedures but with specific and potential life-threatening complications that need to be identified and prevented.

WHAT IS KNOWN ALREADY

There are currently few data on the use of transvaginal ethanol sclerotherapy, and we mainly note septic complications.

STUDY DESIGN, SIZE, DURATION

A retrospective observational cohort study was carried out. The study was conducted at an academic hospital and included 126 women aged 31.9 ± 5.5 years (mean ± SD), between November 2013 and June 2021. We analyzed a total of 157 ethanol sclerotherapy treatment (EST), treated by 131 EST procedures, in 126 women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included women with an indication for transvaginal ethanol sclerotherapy. Indications were women with at least one endometrioma over 10 mm, isolated or associated with other endometriosis locations, requiring treatment for pain or infertility before assisted reproductive treatment. We followed a standardized transvaginal ethanol sclerotherapy procedure consisting of an ultrasound-guided transvaginal puncture of one or more endometriomas under general anesthesia. The cyst content was completely removed and flushed with saline solution. Ethanol (96%) was injected at 60% of the initial volume of the endometrioma, remained in the cyst for 10 min and was then completely removed. Ethanol loss was defined as a loss of 5 ml or more than 10% of the initial volume of the injected ethanol. Failure was defined by the contraindication of endometrioma puncture because of interposition of the digestive tract, ethanol loss in the previous endometrioma treated (in case of multiple ESTs), failure to aspirate the endometriotic fluid, contraindication to start ethanol injection owing to saline solution leakage, or contraindication to continue ethanol injection owing to suspicions of ethanol leakage at sonography. Intraoperative complications were defined by ethanol loss, positive blood alcohol level, and ethanol intoxication. Postoperative complications were defined by fever, biological inflammatory syndrome, and ovarian abscess. Complications were classified according to the Clavien and Dindo surgical classification, which is a system for classifying postoperative complications in five grades of increasing severity.

MAIN RESULTS AND THE ROLE OF CHANCE

We reported a total of 17/157 (10.8%) transvaginal ethanol sclerotherapy failures during 14/131 (10.7%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. In the same sets of data, complication was reported for 15/157 (9.5%) transvaginal ethanol sclerotherapy in 13/131 (9.9%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. Nine of 126 women (7.1%) had a grade I complication, one (0.8%) had a grade II complication (medical treatment for suspicion of pelvic infection), two (1.6%) had a grade III complication (ovarian abscess) and one (0.8%) had a grade IV complication (ethanol intoxication). We did not observe any grade V complications.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study and pain assessment not considered. The benefit-risk balance of endometrioma transvaginal ethanol sclerotherapy was not evaluated.

WIDER IMPLICATIONS OF THE FINDINGS

Our study is the first to evaluate the complications of transvaginal ethanol sclerotherapy with such a large cohort of women in a standardized protocol. Transvaginal ethanol sclerotherapy seems to be an effective alternative to laparoscopic surgery in the management of endometriomas and limits the alteration of ovarian reserve. Transvaginal ethanol sclerotherapy is a reliable, minimally invasive method applicable on an outpatient basis. The majority of complications are Clavien-Dindo ≤IV, for which preventative measures, or at least early diagnosis and treatment, can be easily performed. The risk of ethanol intoxication is rare, but it is a life-threatening risk that must be avoided by appropriate implementation and promotion of the sclerotherapy procedures.

STUDY FUNDING/COMPETING INTEREST(S)

None.

TRIAL REGISTRATION NUMBER

Aix Marseille University's ethics committee registration number 2021-06-03-01.

Synchronous bilateral ovarian torsion followed by recurrent unilateral torsion in a patient undergoing fertility treatment: A case report and literature review

BACKGROUND

Ovarian torsion (OT) is a gynaecological emergency and requires prompt recognition and treatment in order to prevent the loss of ovarian function. Patients who are undergoing fertility treatment are at an increased risk of developing OT.

OBJECTIVE

The diagnosis of OT in patients undergoing fertility treatment can be challenging as they often present with abdominal pain and other non-specific symptoms. We highlight the importance of early diagnosis of suspected torsion and performed a literature review on cases of bilateral OT to review its presentation, investigation, and subsequent management.

CASE REPORT

A 32-year-old nulliparous woman who was undergoing controlled ovarian stimulation presented with lower abdominal pain and was initially managed as ovarian hyperstimulation syndrome (OHSS). Her pain did not subside following conservative management and she proceeded to have a laparoscopy which demonstrated synchronous bilateral ovarian torsion (SBOT), both ovaries were detorted. Eight months later, she was preparing for her frozen embryo transfer (FET) cycle, patient again presented with significant right sided abdominal pain and was found to have a recurrent torsion of the right ovary which was again detorted successfully.

CONCLUSIONS

Clinicians should have a low-threshold to investigate and rule out OT in patients who present with lower abdominal pain, especially in those with additional risk factors for torsion. Patients with confirmed torsion can be successfully managed with detorsion of the ovaries. Further research is needed to determine the best management option for patients with recurrent torsion episodes.

Acupuncture and moxibustion for diminished ovarian reserve: A scoping review

OBJECTIVE

Diminished ovarian reserve (DOR) refers to the decreased number and quality of oocytes in the ovary. Acupuncture and moxibustion has a certain effect on DOR; however, the number of studies and reports of research evidence are limited. This study aimed to conduct a scoping review of the clinical research status of acupuncture and moxibustion for treating patients with DOR.

METHOD

PubMed, Cochrane Library, Excerpta Medica database, Allied and Complementary Medicine Database, Chinese Biological Medicine, China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, and Wanfang database were searched from January 2010 to May 2022 using keywords and medical subject heading terms. After applying the inclusion and exclusion criteria, relevant studies were selected. Structured tables and descriptive charts were made to visually express research features by using Excel, Original, IBM SPSS Model 18.0, Adobe Illustrator and other software packages. Report quality was evaluated for Cochrane bias using Review Manager 5.3.

RESULTS

Overall, 851 studies were identified; of these, 90 met the inclusion criteria. The results extracted from these studies were classified into four categories: research characteristics, study type, acupuncture and moxibustion prescriptions, and efficacy observation.

CONCLUSIONS

The quality assessment of acupuncture and moxibustion for DOR is not ideal. Therefore, standardisation and normalisation should be strengthened, and high-quality evidence is needed to further demonstrate the effectiveness of this approach. Due to heterogeneity in DOR diagnosis, the observation index should be updated with reference to the latest research to improve efficacy evaluation.

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).

Outcomes of in vitro fertilization-embryo transfer in women with diminished ovarian reserve after growth hormone pretreatment

The study was to evaluate the in vitro fertilization-embryo transfer (IVF-ET) outcomes in women with diminished ovarian reserve (DOR) after pretreatment with growth hormone (GH). Retrospective propensity score matching study, which included 92 women received GH over 4 weeks pretreatment before their subsequent IVF cycles and 92 matched controls who underwent IVF cycles between July 2017 and August 2018. The evaluation parameters included ovarian response, embryological parameters, and pregnancy outcomes after embryo transfer (ET). The mean number of retrieved oocytes and transferable day-3 embryos were significantly higher after GH pretreatment. The implantation rate, clinical pregnancy rate, and ongoing pregnancy rate per fresh ET cycle were similar between the GH group and control group. In women who either achieved pregnancy or utilized all the embryos resulting from the index stimulation cycle, the cumulative clinical pregnancy rate was significantly higher in women with GH compared to the control group. 4 weeks pretreatment with GH could increase ovarian response to stimulation and then improved IVF-ET outcomes in women with DOR.

Transvaginal ethanol sclerotherapy for an endometrioma in 10 steps

OBJECTIVE

To describe a minimally invasive 10-step technique of ethanol sclerotherapy for the treatment of an endometrioma.

DESIGN

Step-by-step video demonstration of the technique.

SETTING

University tertiary care hospital.

PATIENT(S)

Women with endometriomas defined as persistent endometriotic ovarian cysts between 25 and 100 mm of diameter, confirmed by magnetic resonance imaging.

INTERVENTION(S)

Endometriomas occur in 17%-44% of patients with endometriosis, who generally complain about pelvic pain or infertility. This technique may be offered to patients with endometriomas to preserve fertility. The local institutional review board stated that approval was not required because the video describes a technique and not a clinical case. In our center, all severe endometriosis cases are discussed during a multidisciplinary endometriosis meeting.

MAIN OUTCOME MEASURE(S)

This video presents the procedure divided into the following 10 steps: planning of the surgery; materials; ultrasound examination; transvaginal puncture of the endometrioma; aspiration of the cyst; cytology of the cyst; flushing the cyst with saline solution; injection of 96% ethanol; 10 minutes' exposure to ethanol; and aspiration of ethanol.

RESULT(S)

We presented 10 steps to make the procedure easier to adopt and to reduce the learning curve. This technique may be offered as an alternative to cystectomy.

CONCLUSION(S)

Ethanol sclerotherapy for endometriomas is a rapid outpatient procedure, requiring little equipment for a low cost.

Delay in IVF treatment up to 180 days does not affect pregnancy outcomes in women with diminished ovarian reserve

STUDY QUESTION

Will a delay in initiating IVF treatment affect pregnancy outcomes in infertile women with diminished ovarian reserve?

SUMMARY ANSWER

A delay in IVF treatment up to 180 days does not affect the live birth rate for women with diminished ovarian reserve when compared to women who initiate IVF treatment within 90 days of presentation.

WHAT IS KNOWN ALREADY

In clinical practice, treatment delays can occur due to medical, logistical or financial reasons. Over a period of years, a gradual decline in ovarian reserve occurs which can result in declining outcomes in response to IVF treatment over time. There is disagreement among reproductive endocrinologists about whether delaying IVF treatment for a few months can negatively affect patient outcomes.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of infertile patients in an academic hospital setting with diminished ovarian reserve who started an IVF cycle within 180 days of their initial consultation and underwent an oocyte retrieval with planned fresh embryo transfer between 1 January 2012 and 31 December 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Diminished ovarian reserve was defined as an anti-Müllerian hormone (AMH) <1.1 ng/ml. In total, 1790 patients met inclusion criteria (1115 immediate and 675 delayed treatment). Each patient had one included cycle and no subsequent data from additional frozen embryo transfer cycles were included. Since all cycle outcomes evaluated were from fresh embryo transfers, no genetically tested embryos were included. Patients were grouped by whether their cycle started 1-90 days after presentation (immediate) or 91-180 days (delayed). The primary outcome was live birth (≥24 weeks of gestation). A subgroup analysis of more severe forms of diminished ovarian reserve was performed to evaluate outcomes for patients with an AMH <0.5 and for patients >40 years old with an AMH <1.1 ng/ml (Bologna criteria for diminished ovarian reserve). Logistic regression analysis, adjusted a priori for patient age, was used to estimate the odds ratio (OR) with a 95% CI. All pregnancy outcomes were additionally adjusted for the number of embryos transferred.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean ± SD number of days from presentation to IVF start was 50.5 ± 21.9 (immediate) and 128.8 ± 25.9 (delayed). After embryo transfer, the live birth rate was similar between groups (immediate: 23.9%; delayed: 25.6%; OR 1.08, 95% CI 0.85-1.38). Additionally, a similar live birth rate was observed in a subgroup analysis of patients with an AMH <0.5 ng/ml (immediate: 18.8%; delayed: 19.1%; OR 0.99, 95% CI 0.65-1.51) and in patients >40 years old with an AMH <1.1 ng/ml (immediate: 12.3%; delayed: 14.7%; OR 1.21, 95% CI 0.77-1.91).

LIMITATIONS, REASONS FOR CAUTION

There is the potential for selection bias with regard to the patients who started their IVF cycle within 90 days compared to 91-180 days after initial consultation. In addition, we did not include patients who were seen for initial evaluation but did not progress to IVF treatment with oocyte retrieval; therefore, our results should only be applied to patients with diminished ovarian reserve who complete an IVF cycle. Finally, since we excluded patients who started their IVF cycle greater than 180 days from their first visit, it is not known how such a delay in treatment affects pregnancy outcomes in IVF cycles.

WIDER IMPLICATIONS OF THE FINDINGS

A delay in initiating IVF treatment in patients with diminished ovarian reserve up to 180 days from the initial visit does not affect pregnancy outcomes. This observation remains true for patients who are in the high-risk categories for poor response to ovarian stimulation. Providers and patients should be reassured that when a short-term treatment delay is deemed necessary for medical, logistic or financial reasons, treatment outcomes will not be affected.

STUDY FUNDING/COMPETING INTEREST(S)

No financial support, funding or services were obtained for this study. The authors do not report any potential conflicts of interest.

TRIAL REGISTRATION NUMBER

Not applicable.

Ethanol Sclerotherapy versus Laparoscopic Surgery for Endometrioma Treatment: A Prospective, Multicenter, Cohort Pilot Study

STUDY OBJECTIVE

To compare the cost-effectiveness of ultrasound (US)-guided aspiration and ethanol sclerotherapy versus laparoscopic surgery for benign-appearing ovarian endometrioma.

DESIGN

Prospective, cohort pilot study.

SETTING

Multiple centers, Spain.

PATIENTS

Forty patients with suspected ovarian endometrioma identified by US, with a maximum diameter of 35 to 100 mm, of whom 33 met inclusion criteria.

INTERVENTIONS

The study group (n = 17) underwent US-guided aspiration plus sclerotherapy with ethanol, and the control group (n = 14) underwent laparoscopic cystectomy.

MEASUREMENTS AND MAIN RESULTS

Recurrence, complications, and direct costs were compared. One of 17 sclerotherapy patients recurred (5.9%) compared with 4 of 14 laparoscopic surgery patients (28.6%) (odds ratio 0.18, 0.01-1.53). No serious adverse effects (Clavien-Dindo ≥ III) were observed in the sclerotherapy group; 1 patient in the surgery group had a Clavien-Dindo IIIb complication. Median hospital direct costs were significantly lower in the sclerotherapy group than those in the surgery group-266 euros versus 2189 euros.

CONCLUSION

Ethanol sclerotherapy seems to be cost-effective for endometrioma and also appears to reduce complications. In this pilot study, recurrence was not higher than with conventional surgery.

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.

Gynaecology problems in puberty

With the onset of puberty a range of problems may be encountered by the young girl. Some of these include a range of gynaecological issues relating to delayed onset of puberty, delayed menarche, atypical pubertal changes and the identification of anomalies of the genital tract. The distinction between physiological events and pathological problems is important to avoid unnecessary distress and anxiety. The onset of cyclic hormonal changes also provokes a number of "non-gynaecological" problems - where the link to cyclic hormonal events is often overlooked and an important opportunity to potentially intervene and assist is missed. From a global perspective there are a range of problems that are particularly encountered with the onset of puberty including the risks of sexual violence, which in the setting of having achieved the age of reproductive potential result in unplanned pregnancies, unsafe abortions and adolescent pregnancy all of which pose life threatening risks. Sex education in its broadest sense is important for all young people. Access to contraception for adolescents is vital, such that clinicians across all streams of health care who are involved in the care of young people should take the opportunity to educate and provide this care.

Assisted reproduction in endometriosis

Endometriosis - a disease causing pain and infertility - is encountered in nearly 50% of infertile women. While medical treatment is effective on pain and recurrence of symptoms after surgical excision, it is of no help for treating infertility for which the only options considered are surgery and ART. Surgery enhances the chances of conceiving naturally during the 12-18 ensuing months irrespective of the stage of the disease. Surgery however is of no help when ART is considered, as it does not improve outcome and can only harm the ovarian response to stimulation. Today therefore, ART is commonly the primary option to be considered in women whose infertility is associated with endometriosis and whose ovarian reserve is compromised and/or who are over 35 years of age. When, ART is envisioned it is best to opt for a segmented ART approach with agonist trigger, freeze all and deferred embryo transfer.

Ovarian endometriosis and fertility preservation: a challenge in 2018

Endometriosis is a benign, estrogen-dependent gynecological disorder. It is now well established that three different forms of endometriosis can occur in the pelvic cavity, namely peritoneal endometriosis, ovarian endometriosis and deep endometriotic nodules of the rectovaginal septum. Treatment of endometriosis-associated infertility has been investigated using both medical and surgical modalities. Surgery for ovarian endometriosis can lead to premature ovarian insufficiency (POI) and further infertility, so one of the most important goals of therapy should be preserving fertility. Procedures combining stripping and ablation should be considered the first-line approach for ovarian endometrioma-related infertility, in order to protect the ovarian reserve, which may already be depleted even before surgery. Autotransplantation of ovarian tissue should be considered in case of mandatory radical treatment (oophorectomy), or if conservative treatment poses a risk. For patients at risk of POI, particularly those undergoing gonadotoxic treatment, two main fertility preservation options exist: oocyte vitrification or reimplantation of fresh or frozen ovarian tissue. Both have advantages and disadvantages.

[Effects of ginger-separated moxibustion at Baliao points combined with Bushen Huoxue formula on patients with decreased ovarian reserve function]

OBJECTIVE

To compare the efficacy differences between ginger-separated moxibustion at Baliao points combined with Bushen Huoxue formula and Bushen Huoxue formula alone on patients with decreased ovarian reserve function.

METHODS

Fifty patients of decreased ovarian reserve function were randomly divided into an observation group and a control group, 25 cases in each one. The patients in the observation group were treated with ginger-separated moxibustion at Baliao points combined with Bushen Huoxue formula; the moxibustion was given for 1.5 h, once every seven days, and no treatment was given during menstrual period. The patients in the control group were treated with Bushen Huoxue formula. One-month treatment was taken as one treatment course, and totally three courses were given. The change of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), anti-mullerian hormone (AMH), antral follicle count (AFC), peak systolic velocity (PSV), resistance index (RI) were observed before and after treatment in the two groups.

RESULTS

After treatment, the FSH, FSH/LH and RI were significantly lowered, but the E2, AFC, PSV were significantly increased in the two groups (all P<0.05); the FSH, FSH/LH and E2 in the observation group were lower and AFC was higher than those in the control group (all P<0.05).

CONCLUSION

The ginger-separated moxibustion at Baliao points combined with Bushen Huoxue formula are superior to Bushen Huoxue formula alone in improving ovarian reserve function.

Comparison of various tissue and cell therapy approaches when restoring ovarian, hepatic and kidney's function after chemotherapy-induced ovarian failure

About 1% of women suffer from premature ovarian failure, which leads to a significant deterioration in the life quality. Most often this condition is caused by performed chemotherapy, autoimmune diseases, surgery performed on ovaries, uterus, or fallopian tubes. The aim of this study was to compare different approaches of tissue and cell therapy in restoring the sexual function in case of ovarian failure induced by chemotherapy.

MATERIALS AND METHODS

The study was carried out in BALB/c mice with the modeled ovarian failure, induced by cyclophosphamide and busulfan. The restoration dynamics of ovarian and sexual function, liver and kidneys after application of cryopreserved explants, cryoextract, placental mesenchymal stem cells, those of adipose tissue has been studied.

RESULTS

It has been shown that the use of various methods of cell and tissue therapy has comparable efficacy when treating an ovarian failure induced by chemotherapy. The most rapid and complete restoration of the reproductive system, liver and kidneys was observed when using the placental explants, extract and cells, but not with the use of mesenchymal stem cells of adipose tissue. No recovery of fertility in this experiment was observed.

CONCLUSION

Various methods of cellular and tissue therapy are perspective in treatment of the chemotherapy complications. More effective are placental derivates.

The value of ultrasonographic tubo-ovarian abscess morphology in predicting whether patients will require surgical treatment

OBJECTIVE

To determine if the ultrasonographic morphology of a tubo-ovarian abscess (TOA) could be used to predict if a patient will require surgical treatment.

METHOD

A retrospective cohort study reviewed medical records from patients diagnosed with TOA via ultrasonography between January 2009 and January 2014 at a tertiary referral center in Turkey. Patients with pelvic inflammatory disease and an inflammatory adnexal mass, identified during sonographic examination, were included in the study. Ultrasonographic morphology, demographic characteristics, and clinical and laboratory findings were compared between patients who required surgical treatment and those who did not.

RESULTS

Records were included from 164 patients; medical therapy was successful in 121 (73.8%) patients and 43 (26.2%) required surgical treatment. TOA morphology was identified, using ultrasonography, as unilocular cystic, complex multicystic mass, or pyosalpinx in 56 (34.1%), 73 (44.5%), and 35 (21.3%) patients, respectively. No correlation was present between ultrasonographic TOA morphology and patients requiring surgical treatment (all P>0.05). Multivariate analyses demonstrated that an abscess larger than 6.5 cm in size (P=0.027), fever at admission (P<0.001), and parity greater than two (P=0.026) were independent predictors of patients requiring surgical treatment for TOA.

CONCLUSION

Although increased TOA size, fever at admission, and parity were associated with increased odds of patients with TOA requiring surgical treatment, ultrasonographic TOA morphology was not.

Biochemical, Histopathological and Immunohistochemical Evaluation of the Protective and Therapeutic Effects of Thymoquinone against Ischemia and Ischemia/Reperfusion Injury in the Rat Ovary

AIM

To evaluate the antioxidant effects of thymoquinone (TQ) and to investigate the biochemical, histopathological and immunohistochemical changes in experimental rat ovarian torsion.

METHODS

A total of 48 female adult rats were used in this study and randomly divided into 7 groups: (1) sham operation; (2) bilateral 3-hour ovarian ischemia; (3) 3-hour ischemia and 3-hour reperfusion; (4) and (5) rats were administered 20 and 40 mg/kg of TQ, respectively, before 0.5 h of ischemia, and then 3 h of ovarian ischemia was applied; (6) and (7) 3-hour ovarian ischemia was applied; 2.5 h after the induction of ischemia, rats were administered the same doses of TQ; at the end of 3 h of ischemia, a 3-hour reperfusion was applied. Histologic changes under light microscopy, immunoreactivity for anticaspase-3 and serum levels of malondialdehyde, interleukin-6, catalase and glutathione peroxidase were noted and compared between the 7 groups.

RESULTS

Ischemia and ischemia/reperfusion cause a deterioration of biochemical and histopathological parameters. Administration of TQ seems to reverse these alterations and alleviate the injury. Antioxidant defense mechanisms appear to be enhanced by the administration of TQ.

CONCLUSION

TQ at different doses attenuates ovarian ischemia and ischemia/reperfusion injury in rats.

Adolescent Gynecologic Emergencies

Adolescent females frequently present to the ED with complaints that may be caused by a gynecologic emergency. Differentiating and excluding some of the common and most serious gynecologic emergencies reviewed in this article are critical. Timely and effective treatment of these conditions, once diagnosed, can result in better health outcomes.

Orthotopic transplantation of cryopreserved mouse ovaries and gonadotrophin releasing hormone analogues in the restoration of function following chemotherapy-induced ovarian damage

Therapy advances are constantly improving survival rates of cancer patients, however the toxic effects of chemotherapy drugs can seriously affect patients' quality of life. In women, fertility and premature ovarian endocrine dysfunction are of particular concern. It is urgently we find methods to preserve or reconstruct ovarian function for these women. This study compares GnRHa treatment with ovarian tissue cryopreservation and orthotopic transplantation in a chemotherapy-induced ovarian damage murine model. 56 inbred Lewis rats were divided into 4 treatment groups: Saline control (group I); cyclophosphamide only (group II); cyclophosphamide plus GnRHa (group III); cyclophosphamide and grafting of thawed cryopreserved ovaries (group IV). Body weight, estrous cycle recovery time, ovarian weight, morphology and follicle count, as well as breeding and fertility were compared among groups. Only group IV was able to restore to normal body weight by the end of the observation period and resumed normal estrous cycles in a shorter time compared to other treatment groups. There was a decrease in primordial follicles in all treatment groups, but group III had the greatest reduction. Although, there was no difference in pregnancy, only one animal littered normal pups in group II, none littered in group III and four littered in group IV. Thus, cryopreservation and orthotopic transplantation of ovarian tissue can restore the fertility of rats subjected to chemotherapy in a manner that is superior to GnRHa treatment. We also observed increased rates of hepatic, splenic and pulmonary haemorrhage in group III, suggesting there may be synergistic toxicity of GnRHa and cyclophosphamide.

Recurrence rate of ovarian endometriosis in patients treated with laparoscopic surgery and postoperative suppressive therapy

INTRODUCTION

The testing represented a prospective study that was performed at the Gynaecology and Obstetrics Clinic "Narodni Front" in Belgrade during a two-year period. The study encompassed female patients with ovarian endometrioma operated with laparoscopic surgery. The research objective was to determine the percentage of occurrence of relapses in patients operated for endometriosis of the ovary in relation to the stage of the disease and the type of performed operation, and which were receiving suppressive therapy with gonadotropin-releasing hormone (GnRH) analogues after the surgery compared to those who were not receiving suppressive therapy after the operation.

MATERIALS AND METHODS

The recurrence of endometriosis on the ovary of the test and control groups was monitored during the first year after surgery. In all patients ultrasound checks were done every month during the first six months after surgery, and then every three months for the next six months. In all patients in whom the recurrence, i.e. endometrioma on the ovary larger than three cm was revealed postoperatively by ultrasound, the laparoscopic removal of the endometrioma was performed again as well as the histopathological examination of the material.

RESULTS AND CONCLUSION

There was no statistically significant difference in the distribution of recurrence of endometriosis between the groups formed according to the type of surgical technique (cystectomy or cystotomy). The recurrence of endometriosis occurred later in the group of patients in which the treatment GnRH analogues was applied after the surgical treatment. The recurrence of endometriosis in more severe stages (Stage III and IV) occurs later in the group of patients in which the treatment GnRH analogues is applied after the surgical treatment.

Incidentalomas: initial management

Incidentalomas are increasingly common findings on radiologic studies, causing worry for physicians and patients. Physicians should consider the risk of discovering incidentalomas when contemplating imaging. Patients may assume that incidentalomas are cancer, and may not be aware of the radiation risks associated with repeat imaging. Once incidentalomas are detected, appropriate management is dependent on an informed patient's wishes and the clinical situation. Guidelines are provided for the initial management of eight incidentalomas (pituitary, thyroid, pulmonary, hepatic, pancreatic, adrenal, renal, and ovarian). Patients presenting with pituitary incidentalomas should undergo pituitary-specific magnetic resonance imaging if the lesion is 1 cm or larger, or if it abuts the optic chiasm. Thyroid incidentalomas are ubiquitous, but nodules larger than 1 to 2 cm are of greater concern. Worrisome pulmonary incidentalomas are those larger than 8 mm or those with irregular borders, eccentric calcifications, or low density. However, current guidelines recommend that even pulmonary incidentalomas as small as 4 mm be followed. Solid hepatic incidentalomas 5 mm or larger should be monitored closely, and multiphasic scanning is helpful. Pancreatic cystic neoplasms have malignant potential, and surgery is recommended for pancreatic cysts larger than 3 cm with suspicious features. Adrenal lesions larger than 4 cm are usually biopsied. The Bosniak classification is a well-accepted means of triaging renal incidentalomas. Lesions at category IIF or greater require serial monitoring or surgery. Benign or probably benign ovarian cysts 3 cm or smaller in premenopausal women or 1 cm or smaller in postmenopausal women do not require follow-up. Ovarian cysts with thickened walls or septa, or solid components with blood flow, should be managed closely.

Identification of Clostridium septicum in a tubo-ovarian abscess: a rare case and review of the literature

INTRODUCTION

Tubo-ovarian abscess (TOA) is a conglomerated mass of pelvic organs including the tube, the ovary, and the bowel. The most commonly isolated organisms from TOAs are Escherichia coli (E. coli) and Bacteroides species.

CASE REPORT

We reported a case of Clostridium septicum (C. septicum) infection from a ruptured TOA with atypical clinical features. Culture of intra-abdominal free fluid obtained during surgery yielded C. septicum. VITEK II (bioMérieux, France) automated system was used for advanced identification of the bacteria. Parenteral clindamycin in combination with an aminoglycoside was used. The patient was discharged 19 days after the surgery and was clinically asymptomatic 6 months after the surgery.

CONCLUSION

The differential diagnosis of TOA caused by C. septicum can be difficult, due to the lack of the symptoms. Tissues infected with C. septicum can become necrotic. A combination of early, adequate antibiotic therapy and surgery is the key point of the treatment.

[Comparative study on effect of plum-blossom needle and western medication on follicular maldevelopment]

OBJECTIVE

To observe clinical efficacy of plum-blossom needle for follicular maldevelopment (FM).

METHODS

Fifty cases of FM were randomly divided into a plum-blossom needle group and a medication group, 25 cases in each one. In the plum-blossom needle group, the plum-blossom needle was applied along Thoroughfare, Conception, Governor and Belt Vessel as well as at Pishu (BL 20), Weishu (BL 21), Shenshu (BL 23), Luanchao (Extra), Zigong (EX-CA 1) during the follicular growth phase, once every other day. In the medication group, clomifene (CC) was prescribed for oral administration and human choriogonadotropin (HCG) was given by intramuscular injection, once each day. For both groups, one menstrual cycle constituted one course. After two courses of treatment, follicular development condition, the changes of endometrial thickness and morphology, ovarian resistent index (RI) and pulsatility index (PI), rate of ovulation and pregnancy were compared between the two groups.

RESULTS

After the treatment, the average diameters of the biggest follicle increased in both groups, while the endometrial thickness and morphology in the plum-blossom needle group were superior to those in the medication group (all P < 0.05). Ovarian RI and PI during mature follicular phase in the plum-blossom needle group were inferior to those in the medication group (both P < 0.05). The differences in ovulation and pregnancy rate were not significant statistically between the two groups (both P > 0.05).

CONCLUSION

The plum-blossom needle therapy based on regulating Thoroughfare, Conception, Governor and Belt Vessel could improve the ovarian blood perfusion, promote the follicular growth, increase the ovulation rate of mature follicle and avoid the out-of-sync between growth of follicle and endometrium during the treatment of western medication.

Tuboovarian abscess. Factors associated with operative intervention after failed antibiotic therapy

OBJECTIVE

To evaluate whether size of tuboovarian abscess (TOA) and other clinical characteristics were associated with the need for surgical intervention.

STUDY DESIGN

A retrospective chart review of patients hospitalized at an inner city hospital between January 1998 and December 2007 with the diagnosis of TOA. Demographics, medical history, clinical markers of infection, radiology, pathology, and operative reports were examined. Student's t test and Fisher's exact test were utilized to analyze differences between groups. Multiple logistic regression analysis was performed to identify significant predictors of surgery. Receiver operating characteristic (ROC) analysis was used to assess how well TOA size and other significant variables were associated with the need for operative or procedural intervention.

RESULTS

A total of 163 patients with TOA were identified; 41 patients were excluded based on specific criteria. Of the remaining 122 women, 65.6% responded to antibiotic therapy, and 34.4% had surgery or ultrasound-guided drainage. Mean TOA size in the medical group was 4.4 cm as compared to 7.3 cm in the surgical group (p < 0.0001). Maximal leukocyte count, older age, and parity were associated with significantly higher risk of surgery. The significant univariate variables remained significant after multivariate analysis. ROC curve analysis revealed an excellent discrimination of the need for surgical treatment as predicted by TOA size, with increased likelihood of surgical or procedural intervention with increasing TOA size.

CONCLUSION

Radiographic size, leukocyte count, age, and parity are associated with operative or procedural treatment of tuboovarian abscess.

Tubo-ovarian abscess presenting as an ovarian tumor in a virginal adolescent: a case report

Tubo-ovarian abscess (TOA), a serious complication of pelvic inflammatory disease, unites the fallopian tube and ovary and, is rarely observed in sexually inactive adolescent girls. A pelvic mass, supposedly originating from the ovary, was detected in a 13-year-old sexually inactive girl suffering from abdominal pain and menstrual disorder. Pelvic ultrasonography pointed out a semisolid, hyperechogenic mass of 57x73 mm in the left adnexal area. Laparotomy revealed an unilateral TOA adhering to the bowel and omentum. Abscess drainage and adhesiolysis were performed and postoperative antibiotherapy was administered. TOA should be considered in the differential diagnosis of females with abdominal pain and adnexal mass whether sexual activity is present or not.

Management of ovarian disease in pregnancy

The ovary is a complex structure that is responsible for maintaining the endocrine support for a pregnancy during the first trimester until the placenta is sufficiently developed to assume this role. Most ovarian disorders of pregnancy actually relate to pre-existing ovarian conditions such as polycystic ovary syndrome and premature ovarian insufficiency. Both of these are associated with increased complications in pregnancy and require careful monitoring. Ovarian disorders that are a particular consequence of the hormonal milieu of pregnancy such as pregnancy luteoma (PL) and hyperreactio luteinalis (HL) are rare. However, they have important implications for both the mother and the foetus since they can be confused with ovarian malignancy leading to unnecessary surgery. This review focuses on the salient aspects of management of these ovarian conditions during pregnancy.

Aromatase inhibitors for ovulation induction and ovarian stimulation

Aromatase inhibitors (AIs) were originally developed for the treatment of advanced breast cancer in postmenopausal women. Their use in reproductive medicine has been extensively studied in the past decade. We reviewed the current strategies for ovulation induction for anovulatory women, mostly women with polycystic ovarian syndrome (PCOS), and the scientific basis for use of AIs in reproductive medicine. The AI, letrozole, is effective in ovulation induction in women with PCOS resistant to clomifene citrate and ovarian stimulation for intrauterine insemination and in vitro fertilization (IVF). Letrozole is an attractive option with its oral route of administration, cost, safety profile and effectiveness in ovulation induction and ovarian stimulation. Letrozole has the potential to be the first-line treatment option for ovulation induction in PCOS women, while its use in ovarian stimulation for IVF deserves further study.

Genital schistosomiasis mansoni concomitant to genital tumor in areas of low endemicity: challenging diagnosis

Genital infection by Schistosoma mansoni is usually misdiagnosed in individuals who reside in, or travel to endemic areas. We describe two cases of genital tumor associated with S. mansoni infection manifested by methrorragy. Surgical specimens revealed leiomyomas in both cases associated with S. mansoni. In one of them, granulomas were found in the ovary and in the other they were found in the uterine tube. Although none presented intestinal/hepatic disease, fecal egg excretion was detected in one. Both had elevated pretreatment antibody reactivity to S. mansoni antigen, but follow-up showed different outcomes. Schistosomiasis should be considered as a diagnosis in individuals with methrorragy residing in or having traveled to endemic areas. Since diagnosis follows genital amputation, and cure control is troublesome, improvement of diagnostic tools and follow-up markers are important priorities to decrease schistosomiasis morbidity.

[Influence of electroacupuncture on efficacy of estrogen in regulating hypothalamic reproductive endocrine activity in rats]

OBJECTIVE

To observe the effect of electroacupuncture (EA) on the efficacy of estrogen-induced regulation of reproductive endocrine in ovariectomized (OVX) rats.

METHODS

Thirty SD rats were randomly divided into control, model (OVX), EA-Guanyuan(CV 4), Estrogen (E) and EA+ E groups (n = 6 in each group). OVX model was duplicated by removing the bilateral ovaries. EA (5 Hz/20 Hz, 1- 2 mA) was applied to "Guanyuan" (CV 4) for 30 min, once every other day and for 3 sessions. Estrogen at doses of 0.5 mg/kg and 0. 25 mg/kg was intraperitonealy given to rats in the E group and EA+ E group, respectively. Serum estrogen and cortisol contents were assayed by enzyme linked immunosorbent assay and the expression of hypothalamic gonadotrophin releasing hormone(GnRH)mRNA, G protein-coupled receptor 54(GPR 54)mRNA, kisspeptin-1 (Kiss-l) mRNA and corticotropin releasing hormone (CRH) mRNA were detected by using real time polymerase chain reaction (RT-PCR).

RESULTS

Compared with the control group, the expression levels of GnRH mRNA, GPR 54 mRNA and Kiss-1 mRNA in hypothalamus in the model group were increased significantly (P<0. 05), while the expression of hypothalamic CRH mRNA was down-regulated obviously (P<0. 05), and serum cortisol and estrogen levels were reduced significantly (P<0. 05). In comparison with the model group, the expression levels of hypothalamic GnRH mRNA in the EA, E and EA+ E groups, and those of hypothalamic GPR 54 mRNA and Kiss-1 mRNA in the E and EA+ E groups were down-regulated considerably (P<0. 05); whereas hypothalamic CRH mRNA expression levels in the E and EA+ E groups were up-regulated obviously (P<0. 05),and serum cortisol and estrogen contents in the E and EA+ E groups were increased remarkably (P<0.05). Comparison among the EA and EA+ E groups showed that the effects of EA+ E group were significantly superior to those of EA group in down-regulating hypothalalmic GnRH mRNA and GPR 54 mRNA expression, and in up-regulating hypothalamic CRH mRNA expression and serum cortisol and estrogen contents (P<0.05). No significant differences were found between E and EA + E groups in down-regulating hypothalamic GnRH mRNA, GPR 54 mRNA and Kiss-1 mRNA expression, and in up-regulating hypothalamic CRH mRNA expression and serum cortisol and estrogen levels (P>0. 05).

CONCLUSION

EA-CV 4 is able to potentiate the effects of low-dose of estrogen in down-regulating hypothalamic GnRH mRNA,GPR 54 mRNA and Kiss-1 mRNA expression, and up-regulating hypothalamic CRH mRNA expression and raising serum cortisol and estrogen contents in OVX rats, showing a favorable modulation effect on reproductive endocrine activity.

Treatment approaches in tubo-ovarian abscesses according to scoring system

BACKGROUND

The aim of this study was to define treatment modalities in tubo-ovarian abscesses (TOA) using a scoring system. As there is no scoring system for TAO there is still a controversy on the management. In our opinion, as there is no evidence based TAO management strategy, a scoring system is needed in the management of these patients. For this purpose we prospectively tried to define that may be useful for favoring a treatment modality and the effects of the parameters on the outcome.

METHODS

The study group comprised of hundred and eighty-four patients hospitalized between May 2001 and June 2008. Patients were divided in three groups according to the treatment modality--laparotomy (group 1, n: 122), medical treatment, (group 2, n: 34), and laparoscopic surgery (group 3, n: 28). Antibiotic regimens or other means of treatment strategies were directed according to our scoring system.

RESULTS

Of the patients, 122 underwent laparatomy, 34 received medical treatment and 28 had operative laparoscopy. Intraoperative complications in the group of 122 patients who underwent laparatomy were bowel injury in 8 patients (6.5%) and ureteral injury in six (4.9 %). Fourteen patients (11.4 %) in the laparatomy group suffered from morbidity related to abdominal incision. In the laparoscopy group two patients (7.1 %) had bowel injury.

CONCLUSION

With this study, we propose a scoring system in TOA cases and define treatment strategies accordingly. According to the results of our study, laparoscopy serves the best treatment option. Medical treatment, despite longer follow up, may be suitable in well-selected cases (Tab. 3, Ref. 39). Full Text in free PDF www.bmj.sk.

Term delivery following transvaginal drainage of bilateral ovarian abscesses after oocyte retrieval: a case report

BACKGROUND

Severe postovum retrieval complications such as tuboovarian abscess are rare. We present an early pelvic infection case following egg retrieval.

CASE

A 31-year-old woman with unexplained infertility developed early pelvic infection subsequent to transvaginal oocyte retrieval (TVOR). Broad spectrum antibiotics were administered. Upon persistence of fever and ultrasonographic appearance of probable abscess, transvaginal ultrasound-guided drainage was performed on post-TVOR day 9 as well as posterior colpotomy and T-drain replacement into the cul de sac. Signs and symptoms of pelvic infection improved following drain replacement. Her beta-hCG was found to be positive in the following days. Drain was removed after 3 weeks. Her pregnancy follow-up was uncomplicated. She delivered a healthy baby vaginally at 38 gestational weeks.

CONCLUSION

Early diagnosis with prompt administration of antibiotics and drainage may prevent poor pregnancy outcome in ovarian abscess patients subsequent to transvaginal oocyte retrieval.

Approach to the patient with Turner syndrome

Turner syndrome (TS) occurs in about 1:4000 live births and describes females with a broad constellation of problems associated with loss of an entire sex chromosome or a portion of the X chromosome containing the tip of its short arm. TS is associated with an astounding array of potential abnormalities, most of them thought to be caused by haploinsufficiency of genes that are normally expressed by both X chromosomes. A health care checklist is provided that suggests screening tests at specific ages and intervals for problems such as strabismus, hearing loss, and autoimmune thyroid disease. Four areas of major concern in TS are discussed: growth failure, cardiovascular disease, gonadal failure, and learning disabilities. GH therapy should generally begin as soon as growth failure occurs, allowing for rapid normalization of height. Cardiac imaging, preferably magnetic resonance imaging, should be performed at diagnosis and repeated at 5- to 10-yr intervals to assess for congenital heart abnormalities and the emergence of aortic dilatation, a precursor to aortic dissection. Hypertension should be aggressively treated. For those with gonadal dysgenesis, hormonal replacement therapy should begin at a normal pubertal age and be continued until the age of 50 yr. Transdermal estradiol provides the most physiological replacement. Finally, nonverbal learning disabilities marked by deficits in visual-spatial-organizational skills, complex psychomotor skills, and social skills are common in TS. Neuropsychological testing should be routine and families given support in obtaining appropriate therapy, including special accommodations at school.

Ovarian abscess as a complication of assisted reproduction techniques: a case report

BACKGROUND

AMP makes true great strides these last decades. Logically some complications were noticed even due to ovarian puncture such as hemorrhage, perforation or infection. The aim of this report is to try, through a review of literature, to draw the attention of physicians to a rare entity, ovarian abscess after follicle aspiration for in-vitro fertilization, and to means of prevention.

CASE REPORT

We report a 38-year-old woman who was plainting from lower abdominal pain located in the left iliac fossa one month after failed IVF trial. The pain was associated with fever and vomiting. The patient's past medical history involves 2 myomectomys (2003-2007). On admission, her temperature was 38.9 degrees C and her blood pressure was 90/60 mm Hg. Physical examination found nondistended abdomen. Tenderness to deep palpation in the left lower quadrant, without peritoneal signs, was detected. No masses were palpated. Mild tenderness in the left cul-de-sac was found. A full blood count showed a white cell count of 17,500 cells/mm3 with 84.5% polymorph nuclear cells, CRP 173 mg/dl. Pelvic ultrasound shows a left latero uterine mass; right ovary and the uterus are unremarkable; there was no free abdominal fluid. The laparotomy was performed 24 hours later and a left ovarian abscess was found. The treatment was conservative. Antibiotics were associated during 15 days. The clinical evolution was satisfying.

CONCLUSION

The ovarian puncture might be technically difficult, incomplete, and even impossible which exposes to a greater infection risk. An ultrasound evaluation of ovarian accessibility is necessary before starting an IVF attempt, especially in case of overweight or history of abdominal or pelvic surgery, endometriosis, tubal abnormalities or myomas. The treatment is based on surgery and antibiotics.

Ruptured tuboovarian abscess and septic shock with Clostridium perfringens in a postmenopausal woman: a case report

BACKGROUND

Clostridium perfringens is the most common causative organism of gas gangrene, a necrotizing infection of soft tissue classically associated with traumatic injuries. Recently, awareness of its occurrence in spontaneous nontraumatic contexts has been increasing. The authors report an unusual case of nontraumatic/spontaneous C perfringens gas gangrene localized to the adnexae.

CASE

A 55-year-old woman presented with abdominal complaints and had surgery because the computed tomographic finding of air in the abdomen led to a preoperative diagnosis of perforated bowel. An infected, draining, right tuboovarian complex and infected left tube were removed. The patient had a stormy postoperative course and was ultimately diagnosed with C perfringens infection/sepsis; she had to be readmitted over a month after discharge for drainage of a pelvic abscess, also due to clostridial infection. The patient ultimately underwent hysterectomy with removal of remaining adnexa. The hysterectomy specimen revealed endometrial carcinoma.

CONCLUSION

C perfringens can cause adnexal infection in the absence of trauma. Diagnosis may be difficult. Timely, aggressive surgical and medical therapy is imperative. When such cases occur, malignancy should be suspected.

Tuboovarian abscess mimicking intraligamentar uterine myoma and a intrauterine device: A case report

A case study is presented of tubo-ovarian abscess (pathohystological-verified actinomycosis) in a 41-year-old woman with an intrauterine device (IUD), which on US was found to be imposed upon an intraligamentary degenerated myoma (pyomyoma). The patient was afebrile, with normal vital functions (diuresis, blood pressure and pulse). Exposure of the abdominal cavity by lower transverse laparotomy performed under general endotracheal anaesthesia revealed slight uterus enlargement with normal left adnexa, whereas right adnexa were not exposed due to the soft tumour in the region of the right ligamentum latum, which displaced the urinary bladder and uterus leftward. The peritoneum fold was incised and deprepared, revealing a tumorous formation imposed onto the myoma or onto the 'cold' tubo-ovarian abscess. Total hysterectomy was then performed. Left adnexa showed a normal finding. Hemalaun-eosin staining of the preparation of the tumour capsule and tumour content showed colonies of threads extending radially to the surrounding tissues (drusen), surrounded by pus corpuscles, polymorphonuclears and macrophages containing lipids (sulfur granules). The patient was free from disease relapse at 2 years after the procedure. Thus, total abdominal hysterectomy and salpingoophorectomy, along with antibiotic therapy, were the definite mode of treatment for pelvic actinomycosis.

The role of iron in the pathogenesis of endometriosis

BACKGROUND

Endometriosis may cause symptoms including chronic pelvic pain and infertility, and increases susceptibility to the development of ovarian cancer. Genomic studies have started to delineate the wide array of mediators involved in the development of endometriosis. Understanding the mechanisms of endometriosis development and elucidating its pathogenesis and pathophysiology are intrinsic to prevention and the search for effective therapies.

METHOD OF STUDY

The present article reviews the English language literature for biological, pathogenetic and pathophysiological studies on endometriosis. Several recent genomic studies are discussed in the context of endometriosis biology.

RESULTS

Severe hemolysis occurring during the development of endometriosis results in high levels of free heme and iron. These compounds oxidatively modify lipids and proteins, leading to cell and DNA damage, and subsequently fibrosis development. Recent studies based on genome-wide expression analysis technology have noted specific expression of heme/iron-dependent mediators in endometriosis. The heme/iron-dependent signaling pathway of endometriosis, which is providing new insights into the regulation of inflammation, detoxification and survival, is discussed.

CONCLUSION

Several important endometriosis-specific genes overlap with those known to be regulated by iron. Other genes are involved in oxidative stress. Iron has a significant impact on endometriotic-cell gene expression. This review summarizes recent advances in the heme/iron-mediated signaling and its target genes, outlines the potential challenges to understanding of the pathogenesis and pathophysiology of endometriosis, and proposes a possible novel model.

[Urgent hemostatic control with Confact F for ovarian bleeding complicated by an unknown type of von Willebrand disease]

Emergency surgery was performed on a 24-year-old female patient with an unknown type of von Willebrand disease (VWD). The patient suddenly developed lower abdominal pain and was transported to our hospital by ambulance. Based on the diagnosis of ovarian bleeding, emergency surgery was indicated. Ristocetin-cofactor activity (VWF: RCo) was between 7% and 14% by measurement with von Willebrand reagent (Dade Behring, Marburg, Germany). A laparoscopic partial resection of the left ovary was performed under administration of factor VIII/VWF concentrate, Confact F((R)) (Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan). During and after surgery, there was no abnormal bleeding. The results obtained by measurement by the reagent were similar to the levels of VWF: RCo obtained by the fixed platelet agglutination method. The reagent was useful for diagnosing and monitoring the VWF: RCo level to control bleeding in VWD.

[Study on relation of ovary-body surface correlativity with acupoints]

OBJECTIVE

To study the specific regularity of acupoints to treat genital system diseases.

METHODS

A model of inflammatory ovary was developed by injection of 0.08 mL, 10% mustard oil into the ovary of the rat. And the reactive points of plasma extravasarion points on the skin were detected after injection of 0.25 mL evens blue into the tail vein. The relation among the regions of plasma extravasation points, dorsal ganglion of governing ovaries and the acupoints to treat the ovarian diseases was analyzed.

RESULTS

The exudative points mainly distributed at Guanyuan (CV 4)-"Zigong" (EX-CA 1) point-area, "Shenshu" (BL 23)-"Mingmen" (GV 4) point-area, "Changqiang" (GV 1)-"Huiyin" (CV 1) point-area, "Sanyinjiao" (SF 6)-"Zusanli" (ST 36) point-area, "Zhongwan" (CV 12) point-area, "Gansho" (BL 18) area, with the most in the "Guanyuan" (CV 4)-"Zigong" (EX-CA 1) point-area and next at "Shenshu" (BL 23)-"Mingmen" (GV 4) point-area.

CONCLUSION

The reactive point-area of plasma extravasation resulted from inflammation of ovary are identical to the ovary a corr.sponding dorsal ganglion. Acupuncture at the corresponding acupoints of the reactive point-areas has specific regulative action on ovarian functions.

Gonadal brucellar abscess: imaging and clinical findings in 3 cases and review of the literature

We report the cases of 3 patients with brucellar gonadal abscess who were examined with gray-scale and color Doppler sonography. In these 3 cases, sonography revealed a thick-walled avarian (n = 2) or testicular (n = 1) abscess. Duplex Doppler sonography indicated a low-resistance type of flow in all 3 patients. The diagnosis of brucellar gonadal abscess is difficult, because it may have a misleading tumor-like appearance. Awareness of the imaging findings of gonadal abscess in patients with brucellosis and correlation with the results of serologic testing can allow early diagnosis, especially in endemic areas.

Development of a hypertrophic ovarian artery after uterine artery embolization with polyvinyl alcohol particles

Uterine artery embolization (UAE) for the treatment of symptomatic leiomyomata has shown excellent short-term clinical efficacy and minimal complications, yet recurrences after successful treatments at mid- and long-term follow-up have been reported. Exact etiologies for such recurrences have not been fully understood. We present a case of symptom recurrence with the development of a hypertrophic ovarian artery after successful UAE with polyvinyl alcohol particles, successfully treated with ovarian and repeat UAEs.

Orphan nuclear receptor function in the ovary

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