Ethanol sclerotherapy: a treatment option for ovarian endometriomas before ovarian stimulation.

Several surgical treatment modalities have been described in cases of isolated or multiple ovarian endometriotic cysts. The aim of this preliminary study was to investigate and test the efficacy of ethanol sclerotherapy (EST) for recurrent endometriotic cysts, before ovarian stimulation in infertile patients with an adequate ovarian status. In the setting of a prospective comparative study, EST was proposed to 31 infertile patients with recurrence of ovarian endometriomas before inclusion in assisted reproduction cycles. Reproductive outcome was compared with that of patients who had previous laparoscopic cystectomy for recurrent endometriomas. The mean size of endometriomas treated with sclerotherapy was 38.6 +/- 11.2 mm in diameter. Ovarian cysts recurred in 12.9% of cases; at a mean time of 10 months after EST. Ovarian reserve and ovarian response to stimulation were better in the EST group than in the control group. Consequently, clinical and cumulative pregnancy rates of the study group were higher than those of the control group (48.3% versus 19.2%, P = 0.04; and 55.2% versus 26.9%, P = 0.03, respectively). Ethanol sclerotherapy may be a good alternative to surgical management of recurrent endometriotic cysts before assisted reproductive treatment. It could be advised for selected infertile patients.

[Ovarian low malignant potential tumor: how to preserve fertility?]. / Tumeur borderline de l'ovaire : comment préserver la fertilité ?

Ovarian low malignant potential tumor account for 10 to 20 percent of ovarian epithelial tumors. They differ from typical ovarian cancers in that they do not grow into the ovarian stroma. Likewise, if they spread outside the ovary, for example, into the abdominal cavity, they do not usually grow into the lining of the abdomen. These cancers tend to affect women at a younger age than the typical ovarian cancers and are less life-threatening than most ovarian cancers. Guidelines for surgical treatment of borderline ovarian tumors are similar to those for ovarian cancer and include hysterectomy with bilateral salpingo-oophorectomy. However, patients with borderline ovarian tumors tend to be younger than women with invasive ovarian cancer. For many of these patients, fertility is an important issue. Previous studies have suggested the safety of conservative surgery with unilateral salpingo-oophorectomy or cystectomy for patients with stage I borderline ovarian tumors. Despite infrequent data, this observation has been expanded to include women with advanced-stage disease. Recurrence is noted more often after this type of treatment, but does not seem to have a negative effect on survival. Management of conservative treatment (complete staging, cystectomy or oophorectomy, oophorectomy or adnexectomy) are still under debate since none avoids the malignant transformation risk. Thus, close follow-up is mandatory and the optimal moment for final oophorectomy remains unclear. When ovarian preservation is impossible, oocyte/ovarian cryopreservation or emergency ovarian induction before the surgical procedure to obtain embryos are promising but still under evaluated options.

[Evolution of surgical operations for female for stress urinary incontinence in gynaecology departments of Parisian public hospitals between 2002 and 2006]. / Evolution des interventions chirurgicales pour incontinence urinaire d'effort dans les services de chirurgie gynécologique de l'Assistance publique des Hôpitaux de Paris entre 2002 et 2006.

OBJECTIVE: To appreciate the evolution of the current surgical practice for female for stress urinary incontinence (SUI) in the gynaecologic surgery departments of Parisian public hospitals in three different periods of 12 months (2002-2003, 2003-2004, and 2006). PATIENTS AND METHODS: The 16 departments were surveyed by postal questionnaire about their surgical practice for the treatment of female SUI. The number, the type of operation, the type of suburethral tapes and their surgical routes were detailed. RESULTS: The participation rate in the survey was 87.5% (14/16) for the first two studied periods and 75% (12/16) for the last one. The number of SUI procedure decreases between the three periods (586, 505, and 263 procedures, respectively; p<0.001). Suburethral slings represent the technique of choice for SUI (86.2% in 2002-2003; 92.7% in 2003-2004, and 98.1% in 2006). Other practices are exceptional. The transobturator approach has widely progressed and became the preferred one in 2006 (31.1%; 64.5%; 95.4% in 2006; p<0.001). No transobturator route was privileged. TVT procedures have decreased between the three studied periods (48.3%, 36.5%, and 4.6% in 2006; p<0.001). TVT-O is the preferred sling in 2006 (120/258, 46.5% of suburethral tapes). DISCUSSION AND CONCLUSION: Suburethral tape placement is nowadays the main surgical treatment for female SUI amongst members in gynaecology departments in Parisian public hospitals. The transobturator approach is preferred.

[Bladder endometriosis: diagnosis and treatment. A series of 24 patients]. / Endométriose vésicale : diagnostic et traitement. A propos d'une série de 24 patientes.

OBJECTIVE: This study aims to show the treatment outcome in women affected by bladder endometriosis. PATIENTS AND METHODS: Retrospective review of records of 24 women with deep vesical endometriosis treated between 1998 and 2007. RESULTS: All cases had cyclic symptoms even though they were not specific. A percentage of 66% of women had concomitantly deep nodules of the rectovaginal septum and/or uterosacral ligaments. Five patients (20.8%) had previously undergone a transurethral resection (TUR) of the bladder lesion, but this therapy has failed in all cases. Partial cystectomy was carried out in 14 patients (60.8%) and an extramucosal dissection of the endometriotic lesion in nine patients (39.2%). Laparoscopy was used in 19 cases (82.6%). Recurrence of bladder endometriotic lesions was documented in two patients. This was mainly due to an incomplete initial treatment. Success rate, defined by total improvement of symptoms after the initial treatment, was estimated at 86.7% in this series. The only complication encountered was a pelvic hematoma with bladder compression that required a ureteral cannulation (JJ). Seven patients out of 11 became pregnant; four of them were infertile before the surgical treatment. DISCUSSION AND CONCLUSION: Diagnosis of bladder endometriosis is often difficult to make because of its non-specific symptoms. The management is mainly surgical and resection should be complete. TUR is not an optimal treatment for bladder endometriosis.

[Effects of electrostimulation (Veinoplus) on lower limbs venous insufficiency-related symptoms during pregnancy. Preliminary study]. / Effets de l'électrostimulation par Veinoplus sur les troubles circulatoires des membres inférieurs chez la femme enceinte. Etude préliminaire.

OBJECTIVE: To assess if electrostimulation of lower limbs relieves lower limbs venous insufficiency-related symptoms during pregnancy. PATIENTS AND METHODS: A two-step study was conducted. First, a monocentric prospective preliminary study including 30 pregnant women was conducted to assess the effects of electrostimulation on fetal monitoring and uterine contractions. Then, a multicentric prospective non-randomised study including 58 pregnant women with a gestational age between 23 and 33 weeks of amenorrhoea was conducted to evaluate the electrostimulation treatment. This evaluation was based on a clinical examination performed pre- and post-treatment, a CIVIQ questionnaire filled out pre- and post-treatment and a daily diary filled out by the patient during treatment duration. Treatment duration was 21 days including two daily treatment sequences of 20 min. Three groups of patients were identified based on initial intensity of venous insufficiency-related symptoms (group 1 minor symptoms, group 2 moderate symptoms, group 3 severe symptoms). RESULTS: Preliminary study showed no interferences between electrostimulation and fetal cardiac rhythm, uterine contractions and maternal uterine and fetal umbilical arteries Doppler. Concerning the evaluation of the electrostimulation: in group 1, electrostimulation significantly reduced heavy legs sensation (p<0,001) and calves pain (p=0,02) between the beginning and the end of the treatment. The four scores calculated with the CIVIQ questionnaire decreased after treatment and a significant reduction was noted for generalised pain feeling (p=0,04) and psychological impact (p=0,03). In group 2, a significant decrease was noted for tiredness (p<0,001), heavy legs sensation (p<0,001), calves pain (p<0,001) and edema (p=0,02) between the beginning and the end of the treatment. The four scores calculated with the CIVIQ questionnaire significantly decrease after 21 days of treatment. In group 3, a significant decrease of heavy legs sensation (p=0,03) and calves and malleoli perimeters (p<0,05) was noted. After 21 days of treatment, the four scores calculated with the CIVIQ questionnaire significantly decrease (p<0,05). When comparing the three groups, beneficial effects of the treatment are most marked in group 2 regarding subjective symptoms, CIVIQ questionnaire scores and leg pain. According to the patients, effectiveness and tolerance of the treatment ranged from good to excellent in the three groups. DISCUSSION AND CONCLUSION: Electrostimulation is an effective and well-tolerated treatment of lower limbs venous insufficiency-related symptoms in pregnant women. Its use during pregnancy did not show any effects on fetus and pregnancy.

[Cystadenofibroma of the ovary: report of two cases]. / Cystadénofibrome séreux de l'ovaire : à propos de deux cas.

Cystadenofibroma of the ovary is a relatively rare benign tumor. Such tumors are characterised by their malignant macroscopical appearance which may lead to an inappropriate aggressive surgical approach. We present two cases of cystadenofibromas of the ovary. The first has been treated by extensive surgery, including pelvic and para-aortic lymphadenectomy. The second has been treated in a more appropriate way, by conservative surgery.

[Rationalizing progestin-only contraception (except IUS with levonorgestrel)]. / Rationaliser la contraception progestative pure (hors DIU au lévonorgestrel).

Using pure progestin contraception has four main objectives; all pure progestins on the market do not satisfy these four main objectives: (i) not to give artificial estrogens like ethinyl estradiol or any kind of estrogens at high doses. This is necessary when there is an estrogeno-dependent pathology; (ii) to diminish endogen estrogen circulating levels by using anti-gonadotrope progestins; (iii) not to induce dangerous proteins synthesis by a too important estrogenic hepatic impact due to an effect, known as hepatic passage. This is required in case of metabolic pathologies or more largely, in case of important vascular risk factors or also in case of an estrogen-dependent hepatopathy; to diminish hormonal fluctuations for women who have problems due to varying endogen hormones. Knowing each product's pharmacology enables to choose the product best adapted to each clinical situation. When choosing, one has to take into account the contraceptive efficiency, as well as the fact that those products are often given over long periods of time to women with particular pathologies.

[Endometrial ablation using hydrothermablator: results of a French multicenter study]. / Thermodestruction endométriale par la technique HTA (HydroThermAblator): résultats d'une étude multicentrique française.

OBJECTIVE: To evaluate the reproducibility, the feasibility and the functional results of the HydroThermAblator (HTA) technique. PATIENTS AND METHODS: This is a retrospective multicenter study in which 143 patients were enrolled in six French medical centers. Patients suffering from dysfunctional and heavy uterine bleeding were treated using the HTA technique between June 2003 and June 2005. A preoperational questionnaire describing the symptoms as well as a qualitative assessment of bleeding was filled. We report the surgical conditions as well as the per- and postoperative complications. We analyzed the level of patient's satisfaction with this technique using a postoperative questionnaire. RESULTS: The average patient's age was 48 years (37-67 years). Patients described their bleeding as being very significant in 46% of the cases, significant in 36%, normal but postmenopausal in 11% of the cases and unknown in 7% of the cases. Previous treatment for bleeding was prescribed in 42.4% of cases. Forty-two decimal four percent of the patients had myomas on preoperative ultrasound examinations. Four minor operative complications were encountered. Thirteen patients had postoperative complications, most of which were described as pelvic pain. Mean postoperative follow-up time was nine months. There were 72.7% of the patients who were satisfied with the procedure. Forty-four percent of the patients were amenorrheic, 37% were oligomenorrheic and 13% were eumenorrheic. Seven patients underwent hysterectomy. The indication for hysterectomy in half of these patients was persistent menorrhagias. DISCUSSION AND CONCLUSION: The hydrothermablator is a simple and efficient endometrial ablation technique for patients suffering from menometrorrhagias. This technique can be used in patients with uterine myomas and irregular uterine cavity. Hydrothermablation must be carried out under hysteroscopic control, which allows to assess treatment success at the end of the intervention. Histology is compulsory (with the exception of patients with metrorrhagia only), all the more so as cancer cases can remain undiscovered.

[Vaginal or laparoscopic assisted vaginal myomectomy: interest in the double way]. / Myomectomie par voie vaginale ou coeliovaginale : intérêt de la double voie d'abord.

OBJECTIVES: To evaluate vaginal and laparoscopic-assisted vaginal myomectomy in order to find interest and indications of this two-way approach of myomectomy. PATIENTS AND METHODS: Retrospective study of 60 patients operated of a myomectomy by vaginal or laparoscopic-assisted vaginal way between December 1999 and January 2007. RESULTS: Thirty-three patients (55%) profited from an exclusive vaginal myomectomy (group 1) and 27 (45%) from a laparoscopic-assisted vaginal myomectomy (group 2). The vaginal gesture in group 2 was carried out mainly because of difficult dissections of deep interstitial myomes (60%) or for the closing of hysterotomies not accessible by coelioscopic way (40%). Mean operating time, blood loss and length of hospital stay were 120 minutes, 431 ml, 3.2 days in group 1 and 180 minutes, 437 ml, 5.1 days in group 2, respectively. Laparoconversions and notable complications rates were 9% in group 1 and 15% in group 2. DISCUSSION AND CONCLUSION: Laparoscopic-assisted vaginal myomectomy is interesting to widen indications of laparoscopic way for myomectomy. However, considering complications and rate of laparoconversion, it is necessary to define situations against indicating this gesture. The methods of prevention of the infection also remain to be found.

[Stress urinary incontinence and suburetral slings. Implications for sexuality]. / Incontinence urinaire d'effort et bandelette sous-urétrale: implications sur la sexualité

The impact of stress urinary incontinence (SUI) is not limited to physical and psychological consequences classically evaluated for this disease. In fact, some studies emphasize the indisputable existence of sexual disorders directly imputable to SUI. Sexual function is an important evaluation element before and after surgical treatment of SUI. Many validated questionnaires about sexual disorders exist, the most frequently utilized in present literature being the female sexual function index (FSFI). Suburethral slings, in spite of discordant results, do not seem to impair global sexuality of patients, some authors reporting a benefit effect of surgery, related to a decrease of coital incontinence after surgery and a decrease of apprehension before sexual intercourse.

[Surgical treatment for genital prolapse in the very elderly: a continuous series of 43 patients]. / Traitement chirurgical du prolapsus du quatrième âge. A propos d'une série continue de 43 cas.

OBJECTIVES: To evaluate surgical treatment for genital prolapse in patients over the age of 75. PATIENTS AND METHODS: This is a continuous retrospective series of 43 patients operated for genital prolapse between March 2001 and October 2006. Surgical outcomes in terms of anatomical correction as well as urological and proctological results were analyzed. Morbidity and mortality studies were carried out. A satisfaction and quality of life assessment was carried out among 19 patients (44%) by an independent researcher at a distance from the intervention. RESULTS: Morbidity attributable to the surgery was minimal, with no cases of mortality. Mean hospital stay was five days. Anatomical correction was good without troubling urological or proctological consequences. Two surgical options were compared: surgery with vaginal occlusion in 23 patients (53.5%) and vaginal conserving surgery in 20 patients (46.5%). Surgical outcomes and morbidity were equivalent in the two groups. Seventy-nine percent of patients surveyed at a distance from the interventions estimated that the procedure had improved their quality of life. DISCUSSION AND CONCLUSION: Surgical treatment for genital prolapse in the very elderly population is a reasonable therapeutic option. Postoperative evaluation demonstrates good anatomical as well as functional results in the majority of cases.

[Causes and clinical implications of sperm DNA damages]. / Causes et implications cliniques des altérations de l'ADN des spermatozoïdes.

Numerous recent studies involve DNA damages associated with poor fertilization rates, early embryo development defect, and poor quality of conceptus following Assisted Reproductive Technologies (ART). The authors denounce a particularly high rate of miscarriages and childhood cancer or dominant genetic mutations such as achondroplasia, Apert syndrome or aberrant gene imprinting such as Angelman and Beckwith Wiedeman syndromes. Gametes DNA defects have numerous origins which are difficult to determine; they are known to involve hypomethylation, oxydative stress and environmental factors.(adducts formation). DNA defect is also linked to a more or less delayed apoptotic phenomenon. Exposure to radiations or radiofrequency electromagnetic emissions can also induce DNA alterations into the spermatozoa of infertile men. Although the underlying mechanisms are unclear, these DNA defects have obvious consequences on reproduction of mammalian species. Detection of such anomalies before ART, are an important step toward developing strategies for clinical management according to the aetiology.

[Surgical and functional results of rectosigmoidal resection for severe endometriosis]. / Résection rectosigmoïdienne pour endométriose profonde : résultats chirurgicaux et fonctionnels.

OBJECTIVES: Indications of colorectal resection for endometriosis are controversial because of the risk of major complications. This study aims to evaluate the value of different diagnostic tests in decision-making, and to evaluate the surgical results and complications, as well as long-term functional results after surgery. PATIENTS AND METHODS: In the set of a retrospective case series, 50 patients who have been admitted for a colorectal resection because of deep endometriosis were included. Most of them have had an MRI and an endorectal ultrasonography. Specific questionnaires have been proposed in order to evaluate symptoms, sexuality (BISF-W) and quality of life (EHP-30). RESULTS: For the diagnosis of rectal involvement, the sensitivity of MRI and endorectal ultrasonography were 55 and 100%, respectively. Forty-one colorectal amputations and nine partial colorectal resections have been done by 24 laparotomies, two laparoscopies and 24 laparoconversions. Major complications included six (12.5%) digestive fistulas, three (6%) anastomotic strictures, one ureterovaginal fistula and one ureteral stricture. Risk factors associated with digestive fistulas were the association of a vaginal opening (p=0.002) and an additional ileocaecal resection (p=0.007). The mean follow-up period was of 42 months. A significant improvement of dysmenorrhea (p<10(-4)), dyschesia (p<10(-4)), chronic pelvic pain (p<10(-4)), and of some digestive symptoms such as catamenial epreintes (p=0.002) and catamenial diarrheas (p=0.006), was noted. We noted postoperative 14 dysurias, six constipations and 12 rectal polykynesias. Four patients have had deep recurrent lesions. Twenty patients had a desire of pregnancy after the operation, 17 pregnancies were obtained (eight spontaneous and nine by ART) giving birth to 14 living children. Sexuality evaluation was below normal range. The quality of life was improved for most of the items. The global satisfaction was good (91%). DISCUSSION AND CONCLUSION: Colorectal resection for deep endometriosis improve significantly most of the pain symptoms, but the women should have detailed counselling about the risks of major complications and recurrence.

[Update on the progestin-only contraception]. / Mise au point sur la contraception progestative.

Despite the lack of complete data concerning their effects, the use of progestin-only contraception is increasing in France (particularly the intra-uterine device, the subdermal implantation, and microprogestins). These prescriptions include a broad range of molecules and administration of doses. In some cases, prescriptions of progestogens are made out of the marketing authorisation indications (especially for macroprogestins). For all of these reasons, an Expert Advisory Board has been set up in order to answer the 35 questions addressed by an Expert Organization Board. The choice of these questions was based on controversial or nonconsensual points usually encountered in everyday clinical practice. When possible, answers given were strongly supported by data issued from medical literature. In situations where clinical studies were lacking, the Expert Advisory Board answered in the most consensual way. All answers given by the Expert Advisory Board were subsequently submitted to the Expert Assessment Board before the latest validation of this document. The progestogen only contraception has different levels of action (local and/or central) which may vary from one drug to another. Its prescription is granted satisfactory efficacy (the macroprogestins' efficacy has never been evaluated) but requires a strict pill-taking routine (especially for the microprogestin contraception). It has never been demonstrated that the use of progestogen is associated with an increased risk of breast cancer. Nevertheless, analysis of breast cancer and progestogen studies should be carried out carefully. Even though the effects, often misunderstood, of the different progestogens on mineral bone density are likely to vary according to the molecules, in particular due to the plasma estradiol level, there is no direct argument for considering the progestin only contraception as a fracture risk factor. As for the venous thromboembolism risk, progestogens are not considered to be risk factors. The progestogen only contraception is advised in the following cases: bad tolerance of exogenous oestrogens; in order to counteract an endogenous hyperoestrogenosis; metabolic or cardiovascular contraindications to estroprogestin; hormonal fluctuations generating premenstrual dysphoria or catamenial headaches. Lastly, the progestin-only contraception should be used as a prime contraception in some particular situations (breast feeding, adenomyosis...).

[Fetal toxicity of angiotensin-II-receptor inhibitors. Case report]. / Toxicité foetale des antagonistes des récepteurs de l'angiotensine II. A propos d'un cas.

The fetal toxicity of angiotensin-converting enzyme inhibitors (ACEI) is now well known. Sartans which are angiotensin II inhibitors, are supposed to have the same side effects on the fetus as ACEI because of their similar mechanism of action. This is supported by experimental and clinical data. Clinical presentation of fetal exposition to sartans varies from transient oligamnios to permanent renal failure, potentially complicated by Potter syndrome. According to previously reported cases, we report a case of transitory fetal oliguria secondary to the exposure to an angiotensin-II-receptor inhibitor (valsartan) between 19 and 21 weeks' gestation. We discuss the management of pregnancies exposed to angiotensin II inhibitors.

[Efficiency of the transobturator suburethral tape in the treatment of 61 patients presenting intrinsic sphincter deficiency]. / Efficacité de la voie trans-obturatrice dans le traitement de l'incontinence urinaire d'effort par insuffisance sphinctérienne urétrale: à propos de 61 cas.

OBJECTIVES: To evaluate the effectiveness of the transobturator route in the treatment of intrinsic sphincter deficiency in the stress urinary incontinence. PATIENTS AND METHODS: This is a retrospective multicenter study. Sixty-one patients with a low-uretral closure pressure were treated for stress urinary incontinence using the transobturator route. The intrinsic sphincter deficiency was defined according to criteria of the Société internationale francophone urodynamique (Sifud). The satisfaction of the patients was appreciated in postoperative consultation in the short run (six to 12 months) and by using the questionnaire "Contilife" evaluating the quality of postoperative life in the long run. The failure was defined when the patients declared themselves dissatisfied during the postoperative consultation and/or if their "Contilife" score was lower than seven (out of 10). RESULTS: The short-term evaluation reveals a rate of satisfaction of 92%. The questionnaire "Contilife" reveals 70% of very satisfied or satisfied patients. Eighteen percent of failure is noted. The majority of the patients in failure had urinary urgencies and/or overactive bladder. DISCUSSION AND CONCLUSION: Transobturator vaginal tape can be used in the treatment of patients having a low-uretral closure pressure. The patients must be informed of a success rate slightly lower than in women having a primary genuine stress incontinence.

[Evolution of surgical operations for female stress urinary incontinence in Gynaecology departments of Parisian public hospitals between 2002 and 2004]. / Evolution des interventions chirurgicales pour incontinence urinaire d'effort chez la femme dans les services de chirurgie gynécologique de l'Assistance Publique des Hôpitaux de Paris entre 2002 et 2004.

OBJECTIVE: To appreciate the evolution of surgical operations for female stress urinary incontinence. PATIENTS AND METHODS: Sixteen gynaecology departments of Parisian public hospitals were surveyed by postal questionnaire about their surgical practice for the treatment of female stress urinary incontinence in two successive periods, between 1st September 2002 and 31st August 2003 inclusive, and between the 1st of September 2003 and the 31st of August 2004 inclusive. The number, the type of operation, the type of suburethral tapes and their surgical routes were detailed. RESULTS: The participation rate in the survey was 87.5%. Suburethral slings represent the technique of choice for stress urinary incontinence (505 [86.2%] in 2002-2003 and 468 [92.7%] in 2003-2004, P < 0.001). Other practices are exceptional. The transobturator approach has widely progressed between the two periods of the study (157 [31.1%] and 302 [64.5%], P < 0.001), and is more often performed than the ascending retropubic approach (245 [48.5%] in 2002-2003 and 117 [25.0%] in 2003-2004, P < 0.001). DISCUSSION AND CONCLUSION: Suburethral tape placement is nowadays the main surgical treatment for female stress urinary incontinence, in Gynaecology departments in Parisian public hospitals, in particular the transobturator approach.

[Apoptosis of granulosa cells as a predictive marker of in vitro fertilization success?]. / L'apoptose des cellules de la granulosa peut-elle être considérée comme un marqueur prédictif du succès de la fécondation in vitro?

During in vitro fertilization (IVF) morphological criteria are the only means usable today to select embryos before their uterine transfer in order to obtain pregnancy with the best chances of success. Since several years many attempts have been made to find more functional means. Quantification of apoptosis of granulosa cells has been proposed for this purpose. The aim of this review is to take stock of our knowledge on apoptosis and its mechanisms in granulosa cells and to analyse how quantification of these apoptotic cells could be a reliable and predictive marker of success for an attempt of an IVF in terms of pregnancy.

[Levonorgestrel-releasing intrauterine system in the treatment of dysfunctional uterine bleeding: A French multicenter study]. / Efficacité et tolérance du système intra-utérin au lévonorgestrel dans la prise en charge des ménorragies fonctionnelles: étude française multicentrique.

OBJECTIVE: To evaluate the levonorgestrel-releasing intra-uterine system as an alternative to surgical treatment in patients presenting with menorrhagia. PATIENTS AND METHODS: In the set of a prospective multicenter study, 49 patients with menorrhagia resistant to medical treatment and/or referred for hysterectomy or endometrial ablation were included. Medical visits were organized 3, 6, 12, 24 and 36 months after insertion of the levonorgestrel-releasing intra-uterine system. Visual score of menstrual bleeding and satisfaction index were noted on each visit. Transvaginal ultrasound, pap smear, endometrial biopsy, and clinical data were retrieved one month before and 12 months after inclusion for tolerance evaluation. RESULTS: Renouncement rate was 90.0% (95% CI = 80.7-96.6%). After a twelve months follow-up, 86.1% of patients were satisfied or very satisfied with their clinical state. We found a significant increase of hemoglobin rates from baseline (14,0 versus 12,9 g/dl; P < 10(-4)). Similar increases were also found in serum iron and ferritin. DISCUSSION AND CONCLUSION: This study confirms the efficacy of the levonorgestrel-releasing intra-uterine system in the control and reduction of menstrual blood loss in patients with dysfunctional uterine bleeding. The high rate of surgery cancellation is a proof of the potential role of the levonorgestrel-releasing intra-uterine system as an alternative treatment in these patients.

[Ovarian endometriomas: Effect of laparoscopic cystectomy on ovarian response in IVF-ET cycles]. / Endométriomes ovariens: effet de la kystectomie laparoscopique sur la réponse ovarienne en fécondation in vitro.

OBJECTIVE: To investigate the follicular response to controlled ovarian hyperstimulation (COH) in IVF-ET cycles after laparoscopic ovarian cystectomy for large endometriomas. PATIENTS AND METHODS: In the set of a retrospective controlled study, the medical records of 113 infertile women who underwent IVF-ET cycles after laparoscopic surgery were reviewed. The study group (A) consisted of 63 patients with severe pelvic endometriosis and endometrioma excision. The control group (B) consisted of 50 infertile patients with mild or minimal endometriosis. Interventions were laparoscopic ovarian cystectomy in the study group, and COH in both groups. RESULTS: Groups A and B were not different in terms of epidemiologic data. The total numbers of recruited follicles (9.1+/-3.3 vs 10.6+/-4.2; P = 0.001), mature follicles (> or =16 mm) (4.2+/-1.7 vs 4.8+/-2.2; P = 0.04), mature oocytes retrieved (5.8+/-3.8 vs 7.4+/-4.6; P = 0.02), and fertilization rate (48.9+/-34.9 vs 61.8+/-32.1%; P = 0.02) observed in group A were lower than those observed in group B, respectively. While the mean number of rFSH ampoules (75 IU) was increased in group A (38.1+/-20.4) compared to group B (29.3+/-16.4; P = 0.004), cumulative pregnancy rates were similar in both groups (27.5+/-8.8% vs 37.2+/-10.6%; P = 0.37). DISCUSSION AND CONCLUSIONS: Ovarian response was reduced during IVF-ET cycles in patients with history of severe endometriosis and laparoscopic excision of endometriomas compared to women with mild or minimal endometriosis without ovarian surgery.