A Retrospective Study of Risk Factors for Small Bowel Obstruction After Hysterectomy.

BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the incidence of small bowel obstruction (SBO) following hysterectomy and to identify factors that may increase the risk of SBO by route of hysterectomy. METHODS: A retrospective review of the electronic medical records of all hysterectomies completed between January 2011 through July 2013 at our institution was performed. Information on patient demographics, comorbid conditions, and surgical characteristics were collected. All cases were reviewed for documentation of SBO in the immediate or remote postoperative period, up to 5 years post-hysterectomy. RESULTS: Between January 2011 and July 2013, 1630 hysterectomies were performed at Montefiore Medical Center. A minimally invasive technique was employed for 49.8%, including 15.7% vaginal and 33.9% laparoscopic hysterectomies. Of these 1630 cases, 40 SBO's were documented; 30 after an abdominal approach and 10 after a minimally invasive approach. The overall incidence of SBO was 2.4%. A multivariable analysis adjusting for potential confounders demonstrated lower odds of SBO for the minimally invasive approaches combined, compared to abdominal hysterectomy (0.44, 95% confidence interval, 0.20, 0.98, p = .0444). Additional variables independently associated with development of SBO included intra-operative bowel injury and malignancy, whereas intra-operative blood loss and lysis of adhesions were not independently associated with SBO. CONCLUSIONS: After adjusting for confounders including malignancy, abdominal hysterectomy was associated with a significantly higher risk for SBO when compared to minimally invasive hysterectomy. Our study adds to the body of literature supporting a minimally invasive approach to hysterectomy when feasible.

Induction of the LH Surge in Premenarchal Girls Confirms Early Maturation of the Hypothalamic-Pituitary-Ovarian Axis.

PURPOSE: To determine whether premenarchal girls exhibit positive estradiol feedback similar to regularly cycling adult women when given exogenous estradiol. METHODS: This was a prospective clinical cohort study at 2 institutions. Nine girls and 6 women received a 7-day course of transdermal estradiol designed to produce physiologic, mid-cycle circulating estradiol levels. Participants collected daily morning urine for luteinizing hormone (LH), estradiol metabolites (E1c), and progesterone metabolites (Pdg), corrected for creatinine. Main outcomes were percentage increase in LH from nadir to peak and the absolute value of peak LH between the 2 groups, using t testing and linear mixed-effects modeling. RESULTS: All participants exhibited a positive feedback response to estradiol. Adult women had a 532.8% (95% confidence interval [CI]: 253.7-1119) increase in LH after estradiol exposure; premenarchal girls had a 497.9% increase (95% CI: 274.5-903.2; P = .86). The absolute value of the LH surge in women was 9.50 mLU/mgCr (95% CI: 2.59- 43 34.90) and in premenarchal girls was 2.57 mLU/mgCr (95% CI: 0.53-12.49; P = .15). CONCLUSIONS: Premenarchal girls can mount an LH surge proportionally similar to regularly cycling adults. This occurs earlier in puberty than previously believed, in contrast to current dogma that maturation of the hypothalamic-pituitary-ovarian axis occurs after menarche and is the rate-limiting step for the establishment of regular, ovulatory cycles. Failure to achieve regular cycles may instead be due to nutritional or ovarian factors. Young girls who fail to ovulate shortly after menarche may warrant further evaluation for endocrinopathies.

Pregnancy Outcomes After Direct Uterine Myoma Thermal Ablation: Review of the Literature.

The objective of this review is to describe the reproductive outcomes of women after radiofrequency volumetric thermal ablation (RFVTA) of myomas or magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU). This is a literature review of the current case reports of reproductive outcomes after direct myoma thermal ablation at multiple academic and private centers throughout the world. A literature search was performed using PubMed and Medline. All publications that included data of women who underwent radiofrequency myoma ablation or MRgHIFU of myomas and subsequently conceived were included. There were 122 pregnancies after direct uterine myoma thermal ablation, and 20 pregnancies were reported after RFVTA. Of these cases, there was 1 spontaneous abortion and 7 elective terminations. The remaining 12 pregnancies went on to have live full-term deliveries, 9 (75%) by cesarean section and 3 (25%) by vaginal delivery. There were no reports of uterine abnormalities at delivery and 1 delayed postpartum hemorrhage with expulsion of a degenerated myoma. There are 102 reported pregnancies after MRgHIFU. There were 21 spontaneous abortions and 22 elective terminations, 48 deliveries, and 11 ongoing pregnancies at the time of report. There was 1 preterm delivery at 36 weeks due to placenta previa, and the remaining deliveries were full term. The complications reported included vaginal spotting (12.5%), delayed placental separation (4%), and placenta previa (4%). There were no cases of uterine rupture. In summary, RFVTA and MRgHIFU are new minimally invasive alternatives for the treatment of myomas. Further investigation into the reproductive outcomes after these myoma therapies is crucial to determine whether these are appropriate treatment options for women with symptomatic myomas who desire future fertility.

Heterotopic Gestation with Twin Intrauterine Implantation Following Transfer of Three Developmentally-delayed Embryos from Cryopreserved Oocytes: A Case Report.

BACKGROUND: In vitro fertilization (IVF) data suggest improved live birth rates for embryos transferred at the blastocyst versus the cleavage stage. Embryos that have not reached the blastocyst stage by day 5 postthaw have diminished potential for implantation and live birth. Few data exist regarding embryogenesis and optimal timing of transfer for embryos derived from previously cryopreserved oocytes, but we report the case of 100% implantation following transfer of 3 developmentally-delayed embryos derived from cryopreserved oocytes. CASE: A 38-year-old woman cryopreserved 20 oocytes for the purpose of future childbearing. At age 42 she returned to thaw and fertilize 8 oocytes using donor sperm. Embryos were cultured to day 5 postthaw, at which time 1 morula and 2 cleavage-stage embryos were available for transfer. Three-embryo transfer resulted in a heterotopic tubal pregnancy and twin intrauterine gestation. Laparoscopic salpingectomy was performed for the ectopic gestation. The twin intrauterine pregnancy spontaneously reduced to singleton, and the patient delivered a live-born infant. CONCLUSION: While heterotopic and multifetal pregnancy are known risks of multiembryo transfer, 3 lesser-quality embryos derived from cryopreserved oocytes would be unlikely to have high implantation potential. Future studies are needed to delineate timing of embryogenesis events in previously cryopreserved oocytes.

Male adiposity impairs clinical pregnancy rate by in vitro fertilization without affecting day 3 embryo quality.

OBJECTIVE: Male adiposity is detrimental for achieving clinical pregnancy rate (CPR) following assisted reproductive technologies (ART). The hypothesis that the association of male adiposity with decreased success following ART is mediated by worse embryo quality was tested. DESIGN AND METHODS: Retrospective study including 344 infertile couples undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles was performed. Cycle determinants included number of oocytes retrieved, zygote PN-score, total number of embryos available on day 3, number of embryos transferred, composite day 3 grade for transferred embryos, composite day 3 grade per cycle, and CPR. RESULTS: Couples with male body mass index (BMI) over 25 kg m(-2) (overweight and obese) exhibited significantly lower CPR compared to their normal weight counterparts (46.7% vs. 32.0% respectively, P = 0.02). No significant difference was observed for any embryo quality metrics when analyzed by male BMI: mean zygote PN-scores, mean composite day 3 grades for transferred embryos or composite day 3 grades per cycle. In a multivariable logistic regression analysis adjusting for female age, female BMI, number of embryos transferred and sperm concentration, male BMI over 25 kg m(-2) was associated with a lower chance for CPR after IVF (OR = 0.17 [95% CI: 0.04-0.65]; P = 0.01) but not after ICSI cycles (OR = 0.88 [95% CI: 0.41-1.88]; P = 0.75). In this cohort, male adiposity was associated with decreased CPR following IVF but embryo quality was not affected. CONCLUSIONS: Embryo grading based on conventional morphologic criteria does not explain the poorer clinical pregnancy outcomes seen in couples with overweight or obese male partner.

Overweight men: clinical pregnancy after ART is decreased in IVF but not in ICSI cycles.

PURPOSE: To evaluate if elevated male body mass influences success after assisted reproductive technologies METHODS: Retrospective study of 290 cycles. RESULTS: Male body mass index greater than 25.0 kg/m² was associated with significantly lower clinical pregnancy (53.2% vs. 33.6%). Multivariable logistic regression indicated that the likelihood of clinical pregnancy was decreased if the male partner was overweight after in vitro fertilization but not after intracytoplasmic sperm injection (odds ratios: 0.21 [0.07-0.69] vs. 0.75 [0.38-1.49], respectively) after adjustment for number of embryos transferred, sperm concentration, female age and body mass. CONCLUSION: In this cohort, overweight status of the male partner was independently associated with decreased likelihood of clinical pregnancy after in vitro fertilization but not after intracytoplasmic sperm injection. A detrimental impact of higher male body mass was observed after adjusting for sperm concentration, suggesting that intracytoplasmic sperm injection may overcome some obesity related impairment of sperm-egg interaction.