Management of false passage complication during operative hysteroscopy

Background

False passage is a possible complication during operative hysteroscopy and can lead to termination of the intended procedure. The aim of this study is to describe two techniques to overcome the complication of false passage during operative hysteroscopy.

Results

This is a retrospective case series of 9 patients who had a false passage during operative hysteroscopy for Müllerian anomaly or endometrial polyps. The diagnosis was immediately made by visualization of a lattice network of myometrial fibers without normal landmarks of the endometrial cavity and tubal ostia. Once a false passage was suspected, an attempt was made to overcome this complication and complete the intended operative hysteroscopy. The hysteroscope was slowly withdrawn to identify both the false passage and the opening towards the internal cervical os. The hysteroscope was tilted towards the opening to the internal cervical os, and it was carefully advanced under direct vision into the endometrial cavity. In two patients, this technique failed because the opening to the internal cervical os was small, so the bridge of tissue between the internal os and false passage was partially divided using hysteroscopic scissors or a straight resectoscope loop, allowing for entry into the endometrial cavity. The intended procedures were completed successfully in all patients. No intraoperative or postoperative complications occurred as a result of the two techniques.

Conclusions

The techniques described in this study, to overcome false passage during operative hysteroscopy, appear to be safe, effective, and easy to perform. They enable the surgeon to complete the intended procedure.

Minimally invasive management of juvenile cystic adenomyoma: report of three cases

Background

Juvenile cystic adenomyosis (JCA) represents a rare form of focal adenomyosis in young women.

Objectives

To determine safety and effectiveness of minimally invasive surgery (MIS for JCA).

Materials and Methods

Three patients aged 16-30 years old presented with chronic pelvic pain [2016 - 2019]. Hormonal treatment failed in two cases. Cystic lesions in the myometrium (n=2), and the broad ligament (n=1) was detected on transvaginal 2D ultrasound (TV 2D US) and/or magnetic resonance imaging (MRI). The cyst was separate from the endometrium in all the cases, within the myometrium in two patients and in the right broad ligament in one case. The cystic lesions were confirmed on laparoscopy; and laparoscopic excision of the cysts with adequate repair of the myometrial beds were performed in all cases with fertility preservation. Robotic assistance was chosen in one case in an attempt to avoid injury of the fallopian tube based on the cyst location during a previous laparoscopy. The endometrial cavity was entered in one case.

Main outcome measures

Absence of intraoperative complications and relief of presenting symptoms postoperatively.

Results

Pathology report confirmed the diagnosis of JCA is all cases. There were no intraoperative complications. All three patients reported relief of their symptoms 6 to 8 months after surgery. No recurrence of the JCA was reported using TV 2D US in all cases.

Conclusions

MIS could be the treatment of choice for patients with JCA. The technique described in our study is safe, effective, and easy to master in experienced hands.

What is new?

Value of MIS in treatment of patients with JCA.

Correction to: The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum/significant arcuate uterine anomaly in infertile patients in the era of transvaginal 3D ultrasound scan

An amendment to this paper has been published and can be accessed via the original article.

The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum/significant arcuate uterine anomaly in infertile patients in the era of transvaginal 3D ultrasound scan

Background

To determine the accuracy of measurement of internal indentation length on transvaginal 3D ultrasound scan (TV 3D US) in detecting patients with an incomplete uterine septum (IUS) or a significant arcuate uterine anomaly (AUA) based on the actual length as measured on diagnostic hysteroscopy. We compared the mean internal indentation length on TV 3D US and on diagnostic hysteroscopy in patients with IUS or a significant AUA.

Results

This is a retrospective study of 546 patients who were found to have IUS (134) or significant AUA (412) on diagnostic hysteroscopy and who had TV 3D US prior to surgery. The mean internal indentation length measured in millimeter on hysteroscopy was significantly higher than the mean internal indentation length measured on TV 3D US in patients with IUS (16.7 + 5.5 vs 5.5 + 4.2; P < 0.001), in patients with significant AUA (12.9 + 2.8 vs 3.9 + 4.6; P < 0.001), and in the overall population (13.8 + 4.0 vs 4.3 + 4.5; P < 0.001). The same findings were obtained when the comparison was limited to patients who had moderate significant internal indentation length (10–14 mm) and those with significant internal indentation length (15–25 mm).

Conclusion

Data in this study suggests that the mean internal indentation length in patients with IUS or AUA can be underestimated on TV 3D US. A diagnostic hysteroscopy is the only gold standard to make the correct diagnosis in these patients.

The impact of single versus double blastocyst transfer on pregnancy outcomes: A prospective, randomized control trial

OBJECTIVE

To determine if elective single blastocyst transfer (e-SBT) compromises pregnancy outcomes compared to double blastocyst transfer (DBT) in patients with favorable reproductive potential.

METHODS

This Randomized Control Trial included 50 patients with SBT (Group 1) and 50 patients with DBT (Group 2). All women were <35 years and had favorable reproductive potential. Randomization criterion was two good quality blastocysts on day 5. Patients who did not get pregnant or who miscarried underwent subsequent frozen cycles with transfer of two blastocysts (if available) in both groups.

RESULTS

No significant difference was observed in the majority of the demographic data, infertility etiology, ovarian stimulation characteristics and embryology data between the two groups. There was a significantly lower clinical pregnancy (61.2% vs 80.0%), and delivery (49.0% vs 70.0%) rates, but no difference in implantation (59.2% vs 54.0%), miscarriage, or ectopic pregnancy rates between Group 1 and Group 2, respectively. There was a significantly higher multiple pregnancy rate in Group 2 (35.0%) compared to Group 1 (0%) [P=0.000]. When fresh and first frozen cycles were combined, there was a significantly lower cumulative clinical pregnancy (77.6% vs 96.0%, P=0.007) and delivery (65.3% vs 86.0%, P=0.016) rates in Group 1 compared to Group 2 respectively.

CONCLUSIONS

In patients with favorable reproductive potential, although e-SBT appears to reduce clinical pregnancy and live-birth rates, excellent pregnancy outcomes are achieved. Clinicians must weigh the benefits of DBT against the risk associated with multiple pregnancies in each specific patient before determining the number of blastocysts to be transferred.

Pigtail catheter for the treatment of ascites associated with ovarian hyperstimulation syndrome

BACKGROUND

Severe ovarian hyperstimulation syndrome (OHSS) is potentially dangerous. The study aim was to evaluate the efficacy and safety of percutaneous pigtail catheter drainage for the management of ascites complicating severe OHSS.

METHODS

This was a prospective trial conducted at a private IVF centre and a tertiary teaching medical centre. A total of 26 patients with severe OHSS was recruited. Patients were divided into two groups. Patients in group 1 (n = 13) were hospitalized, while patients in group 2 (n = 13) were managed on an outpatient basis. A pigtail catheter was inserted under transabdominal ultrasound guidance and kept in place until drainage ceased. The main outcome measures were resolution of OHSS as determined by symptomatology and laboratory values, time to removal of catheter, patient tolerance of the procedure and complication rate.

RESULTS

The catheter was successfully placed in all patients following one attempt and was kept in place for a mean +/- SD of 12.9 +/- 4.3 days (range 7-24). Average amount of fluid drained was 11.2 +/- 4.3 l (range: 3.35-18.5). An improvement of symptoms and signs was noted 24-48 h after catheter placement in all patients in both groups. Procedure was well tolerated and no complications reported.

CONCLUSIONS

Percutaneous placement of a pigtail catheter is a safe and effective treatment modality for severe OHSS. It may represent an attractive alternative to multiple vaginal or abdominal paracentesis.

Administration of recombinant follicle stimulating hormone in a woman with allergic reaction to menotropin: a case report

This report describes a patient who experienced a generalized allergic reaction to Pergonal during controlled ovarian hyperstimulation in preparation for an intracytoplasmic sperm injection procedure for treatment of severe male factor infertility. The report describes a successful desensitization protocol which allowed the patient to complete her treatment cycle despite the allergic reaction to Pergonal. Subsequently recombinant follicle stimulating hormone was used successfully in inducing follicular growth in the absence of any allergic reactions. Therefore, this report confirms other studies which have suggested that an allergic reaction to human menopausal gonadotropins is due to impurities in such urine-derived products.

Intracytoplasmic sperm injection for treatment of non-obstructive azoospermia

Four cases from a tertiary care teaching medical center were studied to assess the potential of sperm extraction, fertilization and the establishment of pregnancy in couples with non-obstructive azoospermia. Four couples with non-obstructive azoospermia underwent intracytoplasmic sperm injection after testicular sperm extraction. Multiple small biopsies were obtained from each testis under general anesthesia in search for sperm, and to establish a histologic diagnosis. The histopathology includes incomplete maturation arrest, hypospermatogenesis, germ cell hypoplasia and incomplete tubular sclerosis. Testicular sperm extraction resulted in the retrieval of immotile sperm from three patients, and a few motile sperm from one patient. Of 60 oocytes which were injected with testicular sperm, 32 (53.3%) fertilized and 27 of these (84.4%) cleaved. Twelve embryos were transferred to three patients and the remaining 15 embryos were cryopreserved. In one patient, no embryos resulted. One clinical pregnancy was established and a normal female infant, weighing 7 lbs 11 oz, was delivered vaginally in August 1996. This study shows that sperm can be extracted from patients with non-obstructive azoospermia when multiple biopsies are obtained. Fertilization, cleavage, clinical pregnancy and delivery of normal babies can be achieved using intracytoplasmic injection of extracted sperm.

Testicular sperm extraction and intracytoplasmic sperm injection: a simplified method for treatment of obstructive azoospermia

OBJECTIVE

To assess the effectiveness of a simple method of testicular sperm extraction for the treatment of obstructive azoospermia.

DESIGN

Retrospective study.

SETTING

Teaching tertiary medical center.

PATIENT(S)

Seventeen men with obstructive azoospermia.

INTERVENTION(S)

The patients underwent 19 cycles of intracytoplasmic sperm injection (ICSI) using testicular sperm. In 5 cycles, testicular sperm extraction was performed after failed microepididymal sperm aspiration. In 14 cycles, testicular sperm extraction was performed in the office under local anesthesia from the outset. The outcome was compared with ICSI cycles using ejaculated sperm (95 cycles) and epididymal sperm (12 cycles fresh and 9 cycles frozen-thawed).

MAIN OUTCOME MEASURE(S)

Clinical pregnancy and implantation rates.

RESULT(S)

There were no differences in the fertilization, cleavage, implantation, or clinical pregnancy rates among ICSI cycles using testicular, epididymal (fresh or frozen-thawed), or ejaculated sperm.

CONCLUSION(S)

When used in conjunction with ICSI, testicular sperm extraction from small excisional biopsy is a simple and cost-effective method for the treatment of obstructive azoospermia.

Relative bioactivity of endogenous luteinizing hormone during superovulation therapy for in vitro fertilization in normal-cycling women

PURPOSE

Impaired outcome of in vitro fertilization treatment has been related to abnormal luteining hormone (LH) secretion and to the occurrence of a premature LH surge. The purpose of this study was to compare LH serum concentrations, measured by bioassay (LH-b) and immunoassay (LH-i), during early and late follicular phases in normal-ovulatory women who were stimulated with clomiphene, human menopausal gonadotropin (HMG), and human chorionic gonadotropin (hCG), while undergoing in vitro fertilization (IVF) treatment for infertility, due mainly to tubal damage.

RESULTS

Of 22 patients, 15 had an LH surge (surge group) before receiving hCG and 7 did not (nonsurge group). LH-b and LH-i concentrations were higher in the late follicular phase than before clomiphene treatment, but the LH-b/LH-i (B/I) ratios remained unchanged and there were no significant differences between the LH surge and the nonsurge groups. In the surge group, the B/I ratio appeared to fall during the LH surge [presurge values, 5.4 +/- 0.5 (SD) and 5.2 +/- 0.5; surge values, 4.9 +/- 0.6 and later 4.0 +/- 0.6], but the differences were not significant, and in some individuals, the B/I ratio later rose as the LH surge progressed.

CONCLUSIONS

Our findings suggest that interference with IVF outcome by a spontaneous LH surge is due to quantitative and/or exposure time effects on the oocyte, rather than to any qualitative variation in bioactivity of LH.

Elevated progesterone levels in the late follicular phase do not predict success of in vitro fertilization-embryo transfer

OBJECTIVE

To examine the effects of subtle elevation in P levels in late follicular phase on the outcome of IVF-ET cycles, using GnRH agonist (GnRH-a) and hMG +/- FSH protocol.

DESIGN

A retrospective analysis of data.

PATIENTS

Fifty-four patients who completed 63 IVF-ET cycles were treated with midluteal GnRH-a, followed by hMG +/- pure FSH. Depending on serum P levels on the day of hCG administration, patients were divided in two groups. In group 1, P levels were < or = 0.9 ng/mL (conversion factor to SI unit, 3.180) and in group 2, the levels were > 0.9 ng/mL.

RESULTS

Luteinizing hormone levels, on the day of hCG administration, as measured by RIA, were suppressed completely. In cycles with subtle P rise (71%), we observed a significantly higher serum E2 concentration, greater number of mature follicles, and greater number of oocytes retrieved. There were no differences between the two groups in fertilization rate, number of embryos transferred, clinical pregnancy rate, implantation rate, and miscarriage or delivery rates.

CONCLUSIONS

We conclude that in IVF-ET cycles, when pretreated with GnRH-a, P levels may increase on the day of hCG administration despite LH suppression and such elevation may not affect adversely the final outcome.

Fertilization and pregnancy achieved by intracytoplasmic injection of sperm retrieved from testicular biopsies

OBJECTIVE

To determine if intracytoplasmic sperm injection using testicular sperm is effective in the treatment of infertile couples with obstructive azoospermia.

DESIGN

Case report.

SETTING

Tertiary care teaching medical center.

METHODS

Intracytoplasmic sperm injection was performed in two patients using testicular sperm after microsurgical epididymal sperm aspiration failed.

RESULTS

In both cases fertilization and embryos resulted. One patient conceived and delivered triplets. There was no evidence of chromosomal abnormality or congenital malformation.

CONCLUSIONS

Intracytoplasmic sperm injection using sperm extracted from testicular biopsy appears to be effective in the treatment of infertile couples with obstructive azoospermia when microsurgical sperm aspiration fails.

Selection of human spermatozoa by a hyperosmotic two-layer Percoll gradient

OBJECTIVE

To investigate whether a hyperosmotic Percoll solution improves the spermatozoal recovery rate of a two-layer Percoll gradient.

DESIGN

A total of 49 semen samples were prepared by both the conventional two-layer Percoll gradient and a hyperosmotic Percoll gradient.

SETTING

In vitro fertilization laboratory of a tertiary care, university-affiliated hospital.

PATIENTS

Semen samples were obtained from patients attending semen analysis.

MAIN OUTCOME MEASURES

The number of spermatozoa recovered, percentage motility, percentage normal morphology, and their survival at 24 hours were assessed after preparation by both Percoll gradients.

RESULTS

The hyperosmotic Percoll gradient resulted in a significantly higher total and motile sperm recovery rate. The degree of increase in total sperm recovery was significantly higher in abnormal semen samples compared with normal semen samples. Percentage normal morphology of sperm samples prepared by hyperosmotic Percoll was improved compared with conventional Percoll but was only significant in abnormal semen samples. However, percentage motility of sperm samples prepared by the hyperosmotic Percoll was significantly lower than those prepared by conventional Percoll gradients.

CONCLUSIONS

The hyperosmotic two-layer Percoll gradient improved motile sperm recovery but also recovered more immotile sperm, leading to a decrease in percentage motility. This technique may allow us to recover more spermatozoa when we come across samples of low sperm concentration.

Expectations of assisted conception for infertility

OBJECTIVE

To provide reliable prognostic information for couples seeking assisted conception.

DESIGN

Analysis of four years' practice (1988-91).

SETTING

Private university service linked with NHS reproductive medicine services.

PATIENTS

804 couples with various causes of subfertility, median duration five years, median age of women 34 years.

INTERVENTIONS

1280 completed cycles: 950 in vitro fertilisation, 144 gamete intrafallopian transfer, and 186 intrauterine insemination and superovulation.

MAIN OUTCOME MEASURES

Pregnancy and birth rates per cycle and cumulative pregnancy and take home baby rates per couple.

RESULTS

In women under 40 years and men with normal sperm, whatever the cause of infertility, results with in vitro fertilisation improved steadily reaching a pregnancy rate per cycle of 30% (95% confidence interval 26% to 35%) during 1990-1 and birth rate per cycle of 29% (23% to 35%) in 1990. Pregnancy and birth rates for gamete intrafallopian transfer were 36% (28% to 44%) and 26% (17% to 37%) and for intrauterine insemination 18% (12% to 24%) and 16% (10% to 22%). After six cycles cumulative probability of pregnancy was 82% and cumulative take home baby rate 70%. Considering only in vitro fertilisation and gamete intrafallopian transfer after four cycles the pregnancy rate was 78% (66% to 91%).

CONCLUSIONS

Conception is less likely in women over 40 and men with sperm dysfunction. For other couples the prognosis for a live birth is at least as good as for fertile couples if they persist with treatment.

A prospective controlled study of in-vitro fertilization, gamete intra-fallopian transfer and intrauterine insemination combined with superovulation

The relative effectiveness of in-vitro fertilization (IVF), gamete intra-Fallopian transfer (GIFT) and intrauterine insemination (IUI) combined with superovulation in the treatment of infertility were compared in 151 couples undergoing a single cycle of treatment. Treatment was selected as appropriate (IVF for tubal disease, GIFT or IUI/superovulation for nontubal infertility) but possible bias due to non-randomization was overcome by all couples having had favourable fertilization in a previous cycle of IVF. Furthermore, in a preliminary study of initial IVF treatment in 265 couples from whom the study patients were drawn, implantation and pregnancy rates in the diagnostic groups were similar. In the definitive study comparing IVF, GIFT and IUI/superovulation, the pregnancy rate observed with GIFT was highest (40%) but this was not significantly higher than with IVF (28%) or IUI/superovulation (20%). However, the implantation rate per egg transferred by GIFT (21%) was significantly higher than the implantation rate per embryo transferred by IVF (11%). Although the pregnancy rates with GIFT were not statistically greater than with IVF, a significant advantage is likely to be observed in larger groups in view of the better implantation rate. The lower pregnancy rates with IUI superovulation are to be expected because of limited ovarian stimulation, they are nevertheless of comparative interest.

Luteinizing hormone bioactivity in human menopausal gonadotropin/human chorionic gonadotropin-induced cycles

Eight human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG)-induced cycles in four anovulatory women unresponsive to clomiphene citrate plus hCG were studied. Blood samples were obtained for baseline determinations and daily thereafter, 24 hours after the injection of hMG. Serum estradiol (E2), progesterone, follicle-stimulating hormone, and luteinizing hormone (LH) were measured by radioimmunoassay. Bioassayable LH (LH-b) was determined by the immature mice interstitial cell in vitro bioassay for testosterone with LER-907 as the reference standard. Appropriate follicular growth, assessed by pelvic ultrasonography, occurred in all cycles. During induction days mean immunoassayable LH (LH-i) and LH-b levels were suppressed until the E2 concentrations rose to a mean of 1420.5 +/- 149 pg/ml (standard error of the mean), at which time a concurrent rise in LH-b and LH-i levels was observed (130% and 34%, respectively). LH-b/LH-i ratio increased by 63% on the day E2 peaked, indicating enhanced LH bioactivity before hCG administration. Our data suggest that during hMG/hCG-induced cycles, in a high E2 milieu, endogenous or exogenous LH may show a heterogeneity in its molecular content, resulting in enhanced bioactivity relative to immunoactivity.

Evidence for a possible cytosol estrogen receptor deficiency in endocervical glands of infertile women with poor cervical mucus

Endocervical gland estrogen receptor (ER) deficiency has been proposed as a possible cause for the poor cervical mucus (CM) in some infertile women with cervical factor. Cytosol ERs were measured in endocervical tissue obtained by biopsy within 3 days of ovulation (determined by the endogenous luteinizing hormone [LH] surge) in five infertile women with persistent poor preovulatory CM (group 1) and in endocervical tissue obtained in the late follicular phase in eight ovulatory women with excellent CM (group 2). ER concentrations were measured in Fmol/mg protein by the dextran-coated charcoal separation method (New England Nuclear Kit, Boston, MA). CM score evaluation and measurement of serum estradiol (E2) and progesterone (P) levels were performed concomitantly. Serum E2 levels of 123.4 +/- 29.3 pg/ml (mean +/- standard error of the mean [SEM]) in group 1 were comparable to E2 levels of 123.3 +/- 15.0 pg/ml in group 2. Serum P concentrations of 0.9 +/- 0.27 ng/ml in group 1 were comparable to 0.79 +/- 0.29 in group 2. A CM score of 4.6 +/- 0.69 in group 1 was significantly lower than 11.6 +/- 0.53 in group 2 (P less than 0.01). The cytosol ER was negative in four of five women in group 1, whereas in group 2, ER was positive in six, borderline in one, and negative in one subject. This study suggests that cytosol ER may be deficient in some women with cervical factor.