Developing a set of patient-centered outcomes for routine use in endometriosis: An international Delphi study.

INTRODUCTION: There is large variation in individual patient care for endometriosis. A uniform approach to measure outcomes could be incorporated into routine clinical practice to personalize and monitor treatments and potentially improve the quality of care. The aim of this study is to identify a group of patient-centered outcomes for use in routine endometriosis care which are relevant to all patient profiles. MATERIAL AND METHODS: By means of a modified two-round Delphi study with international representation including healthcare professionals, researchers and patient representatives (51 participants, 16 countries) we developed a set of patient-centered measurements. The participants evaluated 47 Patient Reported Outcome Measures (PROMs) and 30 Clinician Reported Outcome Measures (CROMs) regarding their feasibility and relevance for their use in routine endometriosis care. After the two rounds of quotation, meetings of the experts were convened to participate in a final discussion to finalize the consensus of the final set of included measures. RESULTS: The final set of patient-centered outcomes includes six PROMs (measuring symptomatic impact, pain, work productivity and quality of life) and 10 CROMs (measuring clinical, imaging and surgical indicators). A supplementary list of outcomes was added to include important dimensions that were considered essential by the expert panel but are not relevant to all patients. In addition the need for development of specific tools (PROMs) measuring the psychological impact and the impact in sexual activity of endometriosis was highlighted. CONCLUSIONS: We have developed a set of patient-centered outcomes measures in endometriosis care. The selected outcomes comprise the common features for all patients suffering from endometriosis. adapted for use in routine practice. The list of outcomes has been adapted for use in routine practice from which clinicians can chose, depending on their needs.

The Association Between Gastrointestinal Symptoms and Transvaginal Ultrasound Findings in Women Referred for Endometriosis Evaluation: A Prospective Pilot Study.

PURPOSE: To evaluate the relationship between gastrointestinal (GI) symptoms and transvaginal ultrasound (TVUS) findings suggestive of endometriosis. MATERIALS AND METHODS: A prospective design. Women referred for a diagnostic ultrasound due to suspicion of endometriosis completed a Rome III and Pelvic Floor Distress Inventory (PFDI-20) questionnaire for clinical, GI symptoms, before undergoing TVUS. Endometriosis was diagnosed in the presence of endometriomas and/or deeply infiltrative endometriotic (DIE) lesions. Association between lesion sites and GI symptoms was evaluated by univariate and multivariate analysis. RESULTS: The study included 241 women who presented with: dysmenorrhea (89.6 %), dyspareunia (76.3 %), chronic pelvic pain (77.2 %), dyschezia (66 %), hematochezia (15.4 %), subfertility (24.5 %). GI symptoms were present in 25.3-76.8 % and 5.4-55.6 % of Rome III and PFDI-20 questionnaire responses, respectively. TVUS findings were endometriomas (23.2 %), peritoneal adhesions (46.5 %), uterosacral ligament (26.7 %), retrocervical (11.2 %), rectosigmoid (11.2 %), intestinal (4.6 %), and bladder (0.8 %) involvement, and pouch of Douglas (POD) obliteration (15.4 %). There was a high prevalence of peritoneal adhesions, uterosacral ligament involvement, and rectosigmoid and intestinal nodules on TVUS in women with GI symptoms, up to Chi2 = 9.639 (p = 0.013) on univariate and Chi2 = 8.102 (p = 0.005) on multivariate analysis. CONCLUSION: We observed an almost 10-fold increase in DIE lesions in women with GI symptoms. We suggest that the presence of GI symptoms should prompt a referral for endometriosis evaluation and performance of a dedicated TVUS before invasive gastrointestinal procedures.

Fertility success rates in patients with secondary infertility and symptomatic cesarean scar niche undergoing hysteroscopic niche resection.

Cesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain, and associated infertility. Although hysteroscopic niche resection is generally considered an effective treatment to control abnormal uterine bleeding, the impact of surgical resection on fertility outcomes is still uncertain. In the present study, we aimed to evaluate the fertility outcomes of symptomatic patients following hysteroscopic niche resection. The design in this retrospective cohort study is Canadian Task Force classification II-2 and it is carried out in a tertiary medical center (Tel-Hashomer) and a private medical center (Herzliya), both in Israel. We included all patients who underwent a niche resection between 2011 and 2015 following at least one year of infertility. From 2011 to 2015, 39 patients with a symptomatic niche and secondary infertility were treated by hysteroscopic niche resection. The patients' mean age was 37.2 (34-41) years, mean number of gestations was 7.04 (1-16), and mean parity 5.1 (1-14). The mean number of previous cesarean sections was 3.4 (1-6). Before the surgery, 32 patients attempted and failed to conceive spontaneously and seven patients underwent in vitro fertilization (IVF) treatment and failed. One year after the hysteroscopic resection, 18 patients conceived (14 spontaneously and four following IVF), leading to a cumulative pregnancy rate of 46.15%. Among the patients who failed to conceive after at least two IVF cycles prior to the hysteroscopic resection, 42.8% conceived following surgery (three patients out of seven). Hysteroscopic niche resection should be considered an effective treatment in patients suffering from secondary infertility.PrécisHysteroscopic niche resection is a safe option for patients with symptomatic secondary infertility, resulting in acceptable fertility rates.

Clinical Success Rate of Extensive Hysteroscopic Cesarean Scar Defect Excision and Correlation to Histologic Findings.

STUDY OBJECTIVE: Cesarean scar defect (CSD) is often associated with postmenstrual bleeding, infertility, and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients. DESIGN: A retrospective cohort study. PATIENTS: Symptomatic patients treated with hysteroscopic CSD excision who were considered eligible for the procedure when myometrial thickness of 2 mm or more was observed on sonohysterography. SETTING: Tertiary referral center. INTERVENTIONS: Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the CSD was collected for histologic examination. Patients were followed for a minimum of 1 year after hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history and preoperative and postoperative menstruation pattern. MEASUREMENTS AND MAIN RESULTS: Between 2011 and 2016, 95 patients underwent extensive hysteroscopic niche excision; 67 were included in the study, whereas the remaining were lost to follow-up. Patient mean age at the time of the procedure was 38 ± 5.5 years. Twenty-nine patients (43%) had a history of high-order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with postmenstrual bleeding, 26 with secondary infertility (38.8%), and 2 with pelvic pain (2.9%). After hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of postmenstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5 ± 4.8 vs 9.8 ± 4.7, p < .001) was also noted. Histologic evidence for myometrial tissue within the obtained samples was associated with better outcomes. A histologic specimen from patients who experienced significant improvement or resolution of postmenstrual bleeding was more likely to reveal myometrial tissue (p = .04). Of the 26 patients who suffered from infertility, 19 attempted to conceive spontaneously after CSD excision. Of those, 10 patients (52.6%) conceived and 9 delivered at least once (47.36%). CONCLUSION: Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated.

In-office Hysteroscopic Extraction of Intrauterine Devices in Pregnant Patients Who Underwent Prior Ultrasound-guided Extraction Failure.

STUDY OBJECTIVE: To determine an effective method of intrauterine device (IUD) retrieval from pregnant women who had previous unsuccessful ultrasound-guided IUD extraction failure. DESIGN: A retrospective cohort study (Canadian task force classification II-1). SETTING: A gynecology department of an outpatient clinic. PATIENTS: Pregnant patients in their first trimester with IUD in situ who underwent prior unsuccessful ultrasound-guided IUD extraction. INTERVENTIONS: Hysteroscopic IUD extraction guided by transabdominal ultrasound. MEASUREMENTS AND MAIN RESULTS: Between 2011 and 2014, 7 of 8 pregnant patients who had undergone previous failed attempts at IUD retrieval via ultrasound guidance underwent successful removal via ultrasound-guided hysteroscopy performed without anesthesia. The sole patient with extraction failure was in her 12th week of pregnancy, and the procedure was concluded to avoid risk to the fetus. Minimal vaginal bleeding was experienced by 2 patients after the procedure. Seven of 8 patients delivered at term without any obstetric complications. One patient had a miscarriage in her 8th week of pregnancy, 2 weeks after successful IUD removal. CONCLUSION: A novel, easy outpatient hysteroscopic technique without anesthesia is presented in case of failure of previous ultrasound-guided IUD removal in early pregnancy. Results are encouraging in this difficult context.

In Vitro Fertilization Outcomes After Placement of Essure Microinserts in Patients With Hydrosalpinges Who Previously Failed In Vitro Fertilization Treatment: A Multicenter Study.

STUDY OBJECTIVE: To investigate whether hysteroscopic proximal tubal occlusion with Essure microinserts (Conceptus Inc.; Bayer, AG, North Rhine-Westphalia, Germany) can improve pregnancy rates in patients with hydrosalpinges who had failed in vitro fertilization (IVF) treatment. DESIGN: A prospective cohort study. SETTING: University-affiliated tertiary centers. PATIENTS: Twenty-four consecutive women with hydrosalpinges who had failed IVF treatment were included. INTERVENTIONS: Hysteroscopic placement of Essure microinserts for hydrosalpinx blockage followed by IVF treatment. MEASUREMENTS AND MAIN RESULTS: Ongoing pregnancy and live birth rates were recorded. Of the 24 patients undergoing a total of 42 IVF cycles after Essure insertion, 18 (75% of patients and 42.8% of IVF cycle attempts) conceived and 16 delivered live births (66.6% of patients and 38.1% of IVF cycle attempts). CONCLUSION: Hysteroscopic proximal occlusion of hydrosalpinges with Essure microinserts is a valuable alternative to laparoscopic salpingectomy, resulting in reasonable pregnancy rates.

Reproductive Outcome Is Favorable After Laparoscopic Resection of Bladder Endometriosis.

STUDY OBJECTIVE: To assess the reproductive outcome (spontaneous and assisted conception rates) in women who underwent laparoscopic resection of bladder endometriosis. DESIGN: This was a retrospective, observational study analyzing prospectively recorded data (Canadian Task Force classification II-2). SETTING: A tertiary referral center. PATIENTS: Over a 9-year period, we identified 69 consecutive women with symptomatic pelvic endometriosis who underwent laparoscopic resection of bladder endometriosis at our center. INTERVENTIONS: Group A patients (n = 21) had full-thickness endometriotic invasion of the bladder and underwent laparoscopic partial cystectomy. Group B (n = 48) patients had partial endometriotic bladder penetration and underwent partial-thickness excision of the detrusor muscle. Most patients (over 70%) had additional, nonbladder endometriotic lesions, which were also removed during surgery. MEASUREMENTS AND MAIN RESULTS: Fertility outcomes were analyzed in patients who wished to conceive (n = 42), and improvements in symptoms were assessed for all patients. The minimum follow-up after surgery was 36 months. Of the 42 patients who wished to conceive, 35 patients (83.3%) conceived: 16 patients spontaneously and 18 patients after IVF treatment. No difference was observed in fertility outcome between group A (partial cystectomy) and group B (partial-thickness excision of the detrusor muscle). For all patients, long-term follow-up revealed that 80% of the patients (55 patients) had no urinary/endometrial symptoms after surgery. CONCLUSION: Pregnancy rates after laparoscopic surgery for bladder endometriosis by either partial cystectomy or deep excision of the detrusor muscle are favorable, both for spontaneous pregnancy and conception after IVF treatment. Additionally, urinary symptoms were improved for the majority of patients. Based on our findings, it seems warranted to offer laparoscopic surgical management to symptomatic infertile patients diagnosed with bladder endometriosis, even after IVF failure.

Laparoscopic nerve lysis for deep endometriosis improves quality of life and chronic pain levels: A pilot study.

OBJECTIVES: To assess the benefit of surgical management of patients with endometriosis infiltrating pelvic nerves in terms of pain, analgesic consumption, and quality of life (QOL). METHODS: We conducted a retrospective cohort study In an Endometriosis referral center at a tertiary care university affiliated medical center. Patients diagnosed with endometriosis that underwent laparoscopic neurolysis for chronic pain were included. Patients rated their pain before and after surgery and differentiated between chronic pain and acute crises. Patients were requested to maintain a record of analgesic consumption and to evaluate their quality-of-life (QOL). RESULTS: Of the 21 patients in our study 15 (71.5 %) had obturator nerve involvement, 2 (9.5 %) had pudendal nerve involvement and 4 (19 %) had other pelvic nerve involvement. Median postoperative follow - up was of 8 months. All but 2 patients (9.6 %) had significant chronic pain improvement with a mean decrease of VAS of 3.05 (±2.5). Analgesic habits changed postoperatively with a significant decrease of 66 % of patients' daily consumption of any analgesics. Surgery improved QOL in 12 cases (57.1 %) and two patients (9.6 %) completely recovered with a high QOL. CONCLUSION: Neurolysis and excision of endometriosis of pelvic nerves could results in significant improvement of quality of life.

Outcome of subsequent pregnancies post uterine rupture in previous delivery: A case series, a review, and recommendations for appropriate management.

OBJECTIVES: To provide clinicians with concrete solutions on the best management of and counseling for patients in a subsequent pregnancy following uterine rupture. METHODS: A retrospective analysis of patients treated between 2005 and 2020 at Sheba Medical Center was conducted. All patients who had undergone a complete uterine rupture and subsequently had a full-term pregnancy were included. A literature review was conducted using Pubmed database and including previously published literature reviews. RESULTS: Fifteen patients with subsequent pregnancies following uterine rupture were included in our cohort. Mean interval between rupture and subsequent pregnancy was 3.8 years (range 2.2-6.9 years). One patient had repeat uterine rupture of less than 2 cm at 36+5 weeksof pregnancy. A total of 17 studies were selected in this literature review, including a total of 774 pregnancies in 635 patients. The risk of repeated uterine rupture was 8.0% (62/774), ranging from 0% to 37.5%. Overall, the risk of maternal death was of 0.6% (4/635), with only four cases reported in three studies. CONCLUSION: The risk of recurrence after uterine rupture is significant but should not prevent patients from conceiving.

MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis.

OBJECTIVE: MRI was the first imaging technique to permit the visualization of the uterine junctional zone and remains the imaging method of choice to evaluate it and its associated pathology. CONCLUSION: Adenomyosis can be diagnosed using MRI with a diagnostic accuracy of 85%. The most important MR finding in making the diagnosis is thickness of the junctional zone exceeding 12 mm. The principal limitation of MRI is the absence of a definable junctional zone on imaging, which occurs in 20% of premenopausal women.

Patient-Reported Outcome Measures in Endometriosis.

Patient Reported Outcome Measures (PROM) evoke measurements that allow capturing patients' perspectives on their condition. In endometriosis care, physicians' understanding of the effect of the disease and the treatment on patients is often poor. The use of PROMs in endometriosis clinical practice can facilitate patient-provider communication and the implementation of patient-centered care, improve patients' quality of life, as well as provide a tool for patients' self-management of the disease. Today, PROMs are extensively used in research and clinical trials, however they are barely used in clinical practice. The development of digital tools facilitating capturing PROMs can contribute to their use by physicians in routine endometriosis care. However, all PROMs are not adapted to be used in routine care in the context of endometriosis. The objective of this study was to present a catalogue of available PROMs for routine endometriosis care and evaluate them according to selected criteria. To do so, we explored the different PROMs currently in the literature. Consequently, 48 PROM were identified as tools used to evaluate various dimensions of the impact of endometriosis on patients. The selected PROMs were evaluated for their potential to be used as a standard in clinical practice in endometriosis. The selected catalogue of PROMs is the starting point for the integration of digital tools to capture PROMs and the development of patient-centered dashboards to be used by patients and clinicians in endometriosis care and self-management to improve care processes, patient satisfaction, quality of life, and outcomes.

Significant increase in serum hCG levels following methotrexate therapy is associated with lower treatment success rates in ectopic pregnancy patients.

OBJECTIVE: To determine the association between early increase in the serum hCG levels (days 0-4) and treatment success rates following methotrexate therapy in ectopic pregnancy patients. STUDY DESIGN: A level II-2 case-control study of involving 140 patients treated with methotrexate for ectopic pregnancy at the gynecology department in a tertiary care hospital. RESULTS: A logistic regression model for the "failure of treatment" was fitted with serum hCG levels change between day 0 and day 4, patient age, pregnancy age at day-0, and day-0 ß-hCG level as predictors. The logistic regression analysis indicated that having more than 50% increase in the ß-hCG levels between days 0 and 4 significantly (P = 0.011) increases the risk of MTX treatment failure. CONCLUSION: The results of this study indicate that >50% increase in ß-hCG levels between days 0 and 4 significantly increases the risk of methotrexate treatment failure. This novel information could assist patients and physicians in making decisions regarding ectopic pregnancy treatment.

Complications of colorectal resection for endometriosis.

Based on a review of the current literature, we will discuss early and late (more than three months postoperative) complications associated with surgery for colorectal endometriosis resection. The most common surgical complications are: rectovaginal fistulae, anastomotic leakages and abscesses. Postoperative bleeding occurs rarely but has also been reported; and usually requires blood transfusion without surgical interventions. The selection of patients for surgery requires a multidisciplinary approach and complete preoperative imaging work-up by an experienced physician. The surgical procedure is challenging, including resection of all extrarectal DIE lesions, often in a context of patients who already underwent operations. Considering the major complications that may occur, there are three frequently observed risk factors. First is the opening of the vagina at the time of the bowel surgical procedure. However, this is a matter of debate, and experts commonly open the vagina during the procedure, as appropriate, without increasing the rate of complications. Second is excessive use of electrocoagulation, which increases the risk of rectovaginal fistulae and abscesses, due to the risk of necrosis of the posterior vaginal cuff. Third is surgical treatment of low rectal lesions (5-8 cm from the anal verge), which increases the risk of anastomotic leaks. In addition, we refuse to consider functional postoperative complications that affect gastrointestinal and sexual function, as minor complications. These can have a severe impact on the quality of life of young women. Further research is needed to prevent and treat such complications.

The Clinical Significance of Endocannabinoids in Endometriosis Pain Management.

Introduction: Patients with endometriosis often suffer from diffuse and poorly localized severe pain. The current pain management strategies include medical and hormonal therapy, as well as surgery. Medical management of pain is often insufficient and is associated with high rate of recurrence. Better pain management is therefore of urgent need. Methods: Among the various candidates, the endocannabinoid system (ECS) has recently emerged as a relevant pharmacological target for the management of endometriosis-related pain. A computerized literature search was performed to identify relevant studies combining the keywords "endometriosis," "endocannabinoid," "cannabinoid receptor," "THC," and "pain mechanisms." Conclusions: This review describes the multiple and complex pain mechanisms associated with endometriosis. Current data and theories concerning the link between the ECS and pain management for endometriosis patients are presented. Finally, we will discuss which aspects of endometriosis-associated pain can be targeted by modulation of the ECS.

Feasibility and efficacy of repeated hysteroscopic cesarean niche resection.

OBJECTIVE: Cesarean-induced niche can cause symptoms such as abnormal postmenstrual bleeding, pain and associated infertility. Hysteroscopic niche resection is usually a successful treatment, but can result in a failure to improve symptoms or symptoms can recur. In the present study we aim to evaluate the feasibility, effectiveness, and safety of a second hysteroscopic niche resection for patients in whom an initial hysteroscopic resection failed to improve symptoms. STUDY DESIGN: This retrospective cohort study (Canadian Task Force classification II-2) hospital tell hashomer (tertiary center) included all patients who underwent a second hysteroscopic niche resection between 2011 and 2015. MEASUREMENTS: Fertility,obstetric outcomes, clinical outcome and complications were compared between the first surgery and the second RESULTS: Eight patients underwent a second hysteroscopy after failure of the first hysteroscopy to resolve symptoms or after recurrence of symptoms. Abnormal uterine bleeding (AUB) was the most common symptom, occurring in all patients. The average number of days of bleeding per cycle were significantly reduced following the second surgery [14.50 (range 8-21days) vs 11.75 (range 8-20days), respectivelyp=0.009]. The second surgery improved symptoms in 6 out of the 8 patients with AUB and 1 of 2 patients with pain. There were no significant differences in fertility and obstetric outcomes between the first and the second surgery and no complications were reported during any of the surgeries. CONCLUSION: Reintervention with a second hysteroscopic niche resection is both feasible and effective treatment option following a failed first attempt or recurrence of symptoms. The second surgery improved symptoms, especially AUB, with no consequent detrimental effect on obstetric outcomes on our series.

Laparoscopic Findings Associated with Bladder Endometriosis Are Correlated with Disease Severity.

STUDY OBJECTIVE: Bladder involvement is rare in endometriosis. The prevalence is estimated to be ∼1% in patients with endometriosis. However, this figure seems to be an underestimation. The diagnosis of bladder endometriosis might be missed during laparoscopy. The aim of this study was to determine an intraoperative visual score of pelvic lesions that help the surgeon suspect bladder endometriosis. Design, Design Classification: A retrospective analysis was performed on the intraoperative photographs and videos of 69 patients with histological confirmation of bladder endometriosis. SETTING: A tertiary referral center. PATIENTS: Sixty-nine patients with bladder endometriosis were operated on in our center over a 9-year period. INTERVENTIONS: Evaluation and analysis of intraoperative laparoscopic findings. MAIN RESULTS: We found three subtypes of laparoscopic findings that can assist with diagnosing bladder endometriosis. The most prominent sign was named "kissing round ligaments" (Type K), in which the right and left round ligaments appear closer to each other than usual or even touching one another. This sign is strongly associated with full-thickness invasion of the bladder. Other laparoscopic findings that indicated bladder endometriosis were anatomical distortion (Type A) and proximal occlusion of the tubes (Type B). We further define a scoring system for the lesion that correlates with the severity of the bladder endometriosis from superficial lesions to full thickness. CONCLUSION: Bladder endometriosis is a rare condition and often remains undiagnosed. Indeed, even during surgery, bladder endometriosis can be missed if the operator is not aware of the suggestive signs. Operative laparoscopic findings may help the surgeon to diagnose bladder endometriosis, and these signs correlate with the severity of the disease.

Hysteroscopically guided transvaginal ultrasound tubal catheterization-a novel office procedure.

OBJECTIVE: Investigate a novel office hysteroscopic tubal catheterization therapeutic method for proximal tubal occlusion. STUDY DESIGN: Prospective cohort study in a tertiary referral center. We evaluated the procedure on a group of 27 patients that were referred to our unit for proximal tubal occlusion demonstrated by hysterosalpingography, 9 (33.3%) of them with primary infertility and 18 of them (66.6%) with secondary infertility. The intervention included the usage of the modified Novy cornual cannulation set which was inserted through a 5F working cannel during an office operative hysteroscopy, followed by fallopian tube irrigation with saline-air mixture under ultrasonographic imaging. RESULTS: Our series revealed no complication during or after the procedure; anesthesia was not required. One patient lost from follow-up. Of the remaining 26, 10 patients (38.4%) conceived either spontaneously or with treatment by clomiphene or gonadotropine associated with intrauterine insemination. The median time to conception was 5 months (range 4-17). CONCLUSION: We therefore concluded that office hysteroscopic tubal catheterization is a simple (without anesthesia required) option for the treatment of patients suffering from proximal tubal occlusion. Fertility outcomes in our series are comparable to other treatments options for tubal catheterization. Therefore, tubal catheterization should not delay the assisted reproducted techniques if indicated but we propose to include it in a global integrated approach.

Fertility outcome of laparoscopic treatment in patients with severe endometriosis and repeated in vitro fertilization failures.

OBJECTIVE: To evaluate fertility outcomes in infertile women with severe endometriosis (The revised American Fertility Society classification [AFS] 3-4) and repeated IVF failures, who underwent surgery due to exacerbation of endometriosis-related symptoms. DESIGN: Retrospective cohort study. SETTING: University hospital. PATIENT(S): All women who failed IVF treatment before surgery and who underwent laparoscopic surgery for severe endometriosis between January 2006 and December 2014. INTERVENTION(S): All patients were operated by highly skilled surgeons specializing in laparoscopic surgery for advanced endometriosis. Only patients with evidence of endometriosis in the pathology specimens were included in this study. MAIN OUTCOME MEASURE(S): Delivery rate after surgery. RESULT(S): Seventy-eight women were included in the present study. All women were diagnosed with severe endometriosis during surgery (AFS 3-4) and all women had experienced failed IVF treatments before surgery. All women were symptomatic before their surgery. After surgical treatment 33 women (42.3%) delivered. Three women (9%) conceived spontaneously and all other women conceived after IVF treatment. Women who delivered were younger (32.5 [±4.1] years vs. 35.5 [±3.8] years), were less often diagnosed with diminished ovarian reserve before surgery (6% vs. 28.8%), and were more often diagnosed with normal uterine anatomy (by preoperative transvaginal ultrasound and during operation). In addition, performing salpingectomy during surgery was associated with a trend of improvement in delivery rates after surgery (70% in women who delivered vs. 51% in women who failed to deliver). CONCLUSION(S): Symptomatic women with severe endometriosis and repeated IVF implantation failures may benefit from extensive laparoscopic surgery when performed by an experienced multidisciplinary surgical team to improve IVF outcome.

Serum FSH Levels in Coasting Programmes on the hCG Day and Their Clinical Outcomes in IVF ± ICSI Cycles.

Introduction. Coasting is the most commonly used strategy in prevention of severe OHSS. Serum FSH levels measurements during coasting may aid in optimizing the duration of coasting. Objective(s). To study live birth rates (LBRs), clinical pregnancy rates (CPRs), and optimal duration of coasting based on serum FSH levels on the hCG day. Materials and Methods. It is a retrospective study performed between 2005 and 2008 at Barts and The London Centre for Reproductive Medicine, NHS Trust, London, UK, on 349-coasted women undergoing controlled ovarian stimulation (COS) for IVF ± ICSI. The serum FSH level measurements on the hCG day during coasting programme were analysed to predict the LBR and CPR. Result(s). LBR and CPR were significantly higher when the FSH levels on the hCG day were >2.5 IU/L (LBR: 32.5%, P = 0.045 and CPR: 36.9%, P = 0.027) compared to FSH <2.5 IU/L. The optimal FSH cut-off level for LBR and CPR is 5.6 IU/L on the hCG day. The optimal cutoff for coasting is 4 days. Conclusion(s). Coasting may be continued as long as either serum FSH level is > 2.5 IU/L on the hCG day without compromising the LBR and CPR or to maximum of 4 days.

Thirteen cases of isolated tubal torsions associated with hydrosalpinx in children and adolescents, proposal for conservative management: retrospective review and literature survey.

BACKGROUND/PURPOSE: Isolated tubal torsion associated with hydrosalpinx is a rare pathology. Our goal was to analyze the clinical and imaging features and discuss the different treatment options available. METHODS: We retrospectively reviewed all the cases of adnexal torsion treated in our department of pediatric surgery over a 10-year period. We searched 2 electronic databases (Medline and Sciencedirect) and targeted reports published during the same period using the key words tubal torsion and hydrosalpinx. RESULTS: A total of 13 cases, 6 from our hospital and 7 in the medical literature, were identified and analyzed. In 9 (69%) of 13 cases (n = 9/13), torsion and hydrosalpinx occurred on the left fallopian tube. Salpingectomy was performed in 11 of the patients. The resected tubes showed the persistence of ciliated cells associated with signs of moderate ischemic infarction in 50% (n = 3/6) of the cases. CONCLUSIONS: Isolated tubal torsion associated with hydrosalpinx is too often misdiagnosed and treated by salpingectomy regardless of the negative impact on the future reproductive potential of our young patients. As is commonly advocated for ovarian salvage in adnexal torsions, tubal conservation should be favored when possible.