Assessment of ovarian reserve using serum anti-Müllerian hormone after ovarian torsion surgery.

BACKGROUND: The aim of this study was to determine ovarian reserve using serum anti-Müllerian hormone (AMH) level in children who had undergone either ovarian-preserving surgery or oophorectomy because of ovarian torsion. METHODS: Patients aged > 10 years who had undergone surgery for unilateral ovarian torsion were contacted for the study with ethics committee approval. Seventeen patients agreed to be included. RESULTS: A total of 10 patients had undergone ovarian detorsion and seven had undergone oophorectomy. Mean age at operation was 11.6 ± 2.23 years (range, 8-15 years) and 13.2 ± 2.17 years (range, 10-16 years), respectively (P = 0.46). Ovarian torsion was isolated in four patients in the first group, and in three in the second. The remainder had associated benign masses. At the time of this study, mean patient age was 18 ± 2.11 years (range, 14-21 years) with a mean postoperative follow up of 5.9 ± 2.8 years (range, 2-10.5 years). Echogenicity of all preserved ovaries was normal on pelvic Doppler ultrasonography, with presence of antral follicles in six. Three ovaries were smaller than expected for age, although two of these had antral follicles. Mean AMH was 5.54 ± 2.25 ng/mL in the detorsion group and 2.70 ± 2.11 ng/mL in the oophorectomy group (P = 0.04). CONCLUSIONS: The presence of follicles in preserved ovaries after detorsion has been reported previously. AMH is expressed in granulosa cells of growing follicles and its serum level is valuable in assessing the quantitative aspects of ovarian reserve. Preservation of the ovary in children with torsion is justified in terms of future ovarian reserve.

Successful Laparoscopic Surgery without Neuromuscular Blockade in a Patient with Malignant Hyperthermia Susceptibility.

Malignant hyperthermia (MH) is a life-threatening clinical syndrome of hypermetabolism involving skeletal muscle. Susceptibility to MH is inherited in an autosomal dominant manner. Its common trigger is exposure to volatile anesthetic agents or depolarizing muscle relaxants. Deep neuromuscular blockade using muscle relaxants can improve the quality of surgical conditions and prevent cardiorespiratory adverse events during laparoscopic surgery. Here we report a case of successful laparoscopic surgery under anesthetic management without neuromuscular blockade in an MH-susceptible patient. A 22-year-old woman with a family history of MH underwent laparoscopic excision of ovarian endometrioma under total intravenous anesthesia and a posterior transversus abdominis plane block. The surgery was completed uneventfully. Our experience suggests that this type of anesthetic management is useful when performing laparoscopic surgery in MH-susceptible patients.

Pelvic floor muscle assessment on three- and four-dimensional transperineal ultrasound in women with ovarian endometriosis with or without retroperitoneal infiltration: a step towards complete functional assessment.

OBJECTIVES: Previous studies comparing women with deep infiltrating endometriosis (DIE) and healthy controls have underlined an association between pelvic floor muscle (PFM) hypertonic dysfunction and deep lesions. The aim of this study was to compare the morphometry of PFM in women affected by ovarian endometriosis with DIE vs those without DIE in order to assess the impact of retroperitoneal infiltration by the disease on PFM function. METHODS: This was a prospective study conducted between March 2015 and December 2016 on symptomatic women with a clinical and sonographic diagnosis of ovarian endometriosis with or without DIE, scheduled for laparoscopic surgery. We excluded patients with current or previous pregnancy, previous surgery for deep endometriosis, other causes of chronic pelvic pain or congenital or acquired abnormalities of pelvic floor anatomy. Three- and four-dimensional transperineal ultrasound was performed to evaluate PFM morphometry and assess levator hiatal area (LHA) and diameters at rest, during PFM contraction and during Valsalva maneuver. All volumes were analyzed offline by an investigator blinded to the clinical data. RESULTS: One hundred and fourteen patients with ovarian endometriosis were enrolled in the study, 75 with DIE and 39 without DIE. The diagnosis of endometriosis was confirmed by histological examination in all patients. Compared with women without DIE, women with DIE showed a smaller LHA at rest, during contraction and during Valsalva maneuver (P = 0.03, P = 0.03 and P = 0.02, respectively) and a smaller reduction in LHA during PFM contraction (P = 0.04). CONCLUSIONS: Women with ovarian endometriosis who were affected by DIE showed smaller hiatal dimensions than did women without DIE. Considering that PFM dysfunction in patients with DIE could cause pain symptoms and pelvic organ dysfunction, transperineal ultrasound could allow a more complete functional assessment and tailored therapy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Hysterosalpingo-contrast-sonography (HyCoSy) in the assessment of tubal patency in endometriosis patients.

OBJECTIVE: Tubal patency in women with endometriosis has traditionally been evaluated by laparoscopy. The aim of this study was to investigate the accuracy of hysterosalpingo-contrast-sonography (HyCoSy) in the assessment of tubal patency in these women. STUDY DESIGN: A retrospective study was conducted at Physiopathology of Human Reproduction Unit. Infertile women who underwent HyCoSy and then a laparoscopy (dye test) within 6 months from the HyCoSy were included. Tubal patency was assessed by HyCoSy and the findings were compared with the results of laparoscopy, which was considered the gold standard for assessment of tubal patency. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) and positive and negative likelihood ratios (Lh+, Lh-) were calculated including the 95% confidence interval (CI). RESULTS: A total of 1452 women underwent HyCoSy and 126 of them received a laparoscopy within 6 months from the HyCoSy. Of the 126 women, 42 (33.3%) had a diagnosis of pelvic endometriosis and 84 (66.7%) had no endometriosis. In the endometriosis population, HyCoSy showed a sensitivity, specificity, PPV, NPV, Lh+ and Lh- of 85% (95% CI 62-96), 93% (95% CI 82-97), 81% (95% CI 58-94), 94% (95% CI 84-98), 12.6 (95% CI 4.8-33) and 0.15 (95% CI 0.05-0.4) respectively. In the non-endometriosis group, HyCoSy showed a sensitivity, specificity, PPV, NPV, LR+ and LR- of 85% (95% CI 65-95), 93% (95% CI 87-96), 71% (95% CI 53-85), 97% (95% CI 92-99), 13.2 (95% CI 6.9-25) and 0.15 (95% CI 0.06-0.3) respectively. The diagnostic accuracy of HyCoSy was 91% in the endometriosis group and 92% in the non-endometriosis patients. CONCLUSIONS: HyCoSy showed high accuracy in evaluating tubal patency in infertile non-endometriosis women and in those affected by endometriosis.

Subjective assessment of ovarian masses using pattern recognition: the impact of experience on diagnostic performance and interobserver variability.

PURPOSE: To compare diagnostic performance and interobserver variability in a group of 36 examiners, with four different levels of experience. METHODS: Nine junior trainees, eight level I senior trainees, 11 level II senior gynecologists, and eight level III expert sonologists classified 105 ultrasound images of adnexal masses into three subgroups of ovarian lesions (malignancies, functional cysts, and dermoid cysts). RESULTS: The level III sonologists obtained the best diagnostic results together with the lowest interobserver variability (κ = 0.70, SD = 0.04). They achieved significantly better results in comparison with the junior trainees and also the senior trainees (κ = 0.51, SD = 0.12, p < 0.001; and κ = 0.51, SD = 0.09, p < 0.001). Differences between level III sonologists and the group of level II observers did not reach statistical significance (κ = 0.65, SD = 0.09, p = 0.70). There were no significant differences between senior and junior trainees (p = 1.0) and both groups achieved a significantly poorer diagnostic performance in comparison with the level II observers (p < 0.01 and p < 0.01). For all observers, the largest differences were seen for classifying malignancies, the best results for classifying functional cysts, and the poorest for evaluating dermoid cysts. CONCLUSIONS: Diagnostic performance of pattern recognition significantly improves with an increasing level of experience, emphasizing the importance of standardized ultrasound training programs with supervision by experts.

Assessment of cyst content using mean gray value for discriminating endometrioma from other unilocular cysts in premenopausal women.

OBJECTIVE: To assess whether the analysis of cyst content using mean gray value (MGV) can discriminate ovarian endometriomas from other unilocular ovarian cysts in premenopausal women. METHODS: Stored three-dimensional (3D) volumes from 54 unilocular ovarian cysts diagnosed in 50 premenopausal women (mean age, 37 (range, 22-50) years) were analyzed to calculate the MGV from cyst content. Cysts with solid components or septations were excluded. MGV was calculated in all cases with the Virtual Organ Computer-aided AnaLysis technique. The B-mode presumptive diagnosis based on the examiner's subjective impression was also recorded. RESULTS: Sixteen of the cysts resolved spontaneously and were given a final clinical diagnosis of hemorrhagic functional cyst, while 38 cysts were removed surgically (diagnosed histologically as seven simple cysts, three hemorrhagic cysts, 20 endometriomas, five mucinous cysts and three paraovarian cysts). B-mode diagnoses were as follows: seven simple cysts, 18 hemorrhagic cysts, 24 endometriomas, three mucinous cysts and two paraovarian cysts. MGV was significantly higher in ovarian endometrioma when compared with all other kinds of cyst. The receiver-operating characteristics curve showed that using an MGV cut-off >or= 15.560 had a sensitivity of 85% and a specificity of 76.5% for diagnosing ovarian endometrioma (area under the curve, 0.831; 95% CI, 0.718-0.944). These figures were similar to those for B-mode diagnosis (sensitivity, 90%; specificity, 82%) (McNemar test, P = 1.000). Combining B-mode and MGV gave a sensitivity of 80% and a specificity of 91%. CONCLUSION: Cyst content MGV is higher in ovarian endometrioma than it is in other unilocular ovarian cysts. The diagnostic performance of MGV is similar to that of the examiner's subjective impression. The combination of both criteria achieves the highest specificity.

Clinical assessment, gross examination, frozen section of ovarian masses: do patients benefit?

OBJECTIVE: The overall risk of malignancy in ovarian neoplasm is 13% in premenopausal women and 45% in postmenopausal women. Differentiating benign and malignant disease with frozen section is possible during operation; however, information on patients' history, physical examination, paraclinical criteria (tumour markers, imaging) and gross examination of tumour can also be helpful in planing the surgery. METHODS: This study was conducted on 150 women who underwent laparotomy due to adnexal mass between April 2003 and October 2005 at Vali-e-Asr Hospital, Tehran, Iran. Sensitivity and specificity of clinical assessment (history, tumour marker and imaging), gross examination and frozen section were calculated. RESULTS: Based on our findings frozen section had the highest sensitivity for diagnosing malignant tumour comparing with other methods of diagnosis (88.9%). Sensitivity was 71.3% for preoperative clinical examination, 83% for ultrasonography, 89.8% for CT scan, 70% for CA125 and 84.1% for gross examination, likewise the highest specificity was seen for frozen section (93.5%). CONCLUSION: This data confirm that frozen section diagnosis is a reliable method for the surgical management of patients with an ovarian mass, but history of disease, Para clinical criteria and gross examination can help to surgeon to perform on appropriate operation in the areas where frozen section is not possible.

[Clinical assessment of selected vascularization attributes of adnexal masses in preoperative prediction of tumor malignancy]. / Ocena przydatnosci klinicznej indeksu waskularyzacji w diagnostyce przedoperacyjnej guzów jajnika.

OVERVIEW: Preoperative differential diagnosis of adnexal masses has been a challenge for researchers for years. Prediction of tumor malignancy is essential for selection of optimal treatment with lowest risk for patient. Assessment of various tumor vascularization attributes, using color Doppler semi-quantitative analysis, can be helpful for malignancy differentiation. OBJECTIVES: To assess value of selected vascularization attributes of adnexal masses in preoperative prediction of tumor malignancy. MATERIALS AND METHODS: This study included 521 women diagnosed and treated for adnexal masses (181 malignant and 340 benign) in Obstetrics and Gynecology Hospital of University of Medical Sciences in Poznan between 1994 and 2004. All of them underwent color Doppler examination using Aloka 2000 and 5500 devices (vaginal probes 5,0-6,5 MHz, abdominal probes 3,5-5 MHz) with evaluation of such attributes as: vessels count, localization and structure; semi-quantitative scale was also constructed basing on these parameters. RESULTS: There was a significantly higher number of vessels (cut-off value=4; p < 0.0001), central vessels localization (p < 0.0001) and irregular structure of vessels (p < 0.0001) in patients with confirmed malignant tumor. Constructed semi-quantitative Doppler scale resulted in highest diagnostic accuracy (cut-off value = 3; p < 0.0001). CONCLUSIONS: Central vessels localization was the single most significant attribute in tumor malignancy differentiation. Constructed semi-quantitative Doppler scale resulted in highest diagnostic accuracy and can be a useful tool in preoperative prediction of tumormalignancy.

Power Doppler in the assessment of pelvic masses in a low risk group.

Discrimination between benign and malignant adnexal masses aids in optimising the management of women with pelvic tumours. A grading system incorporating grey-scale and power Doppler measurements might increase the accuracy of pre-operative assessment. The present study aimed to assess the sensitivity and specificity of a grading system including grey-scale and power Doppler findings. A total of 179 women who had undergone power Doppler Ultrasound for a pelvic mass between April 2001 and March 2003 were identified. Masses were surveyed by grey-scale and power Doppler and graded in relation to the estimated risk of malignancy. Clinicians were provided with the findings. The results were compared with the findings at surgery. A total of 74.3% were premenopausal. Some 94.4% (n = 169) had benign; 1.7% borderline and 3.9% malignant histology. A total of 69% underwent surgery. Specificity was 72.2 - 95.9%; sensitivity 55.6 - 88.9% and negative predictive value 97.6 - 99.2%. Power Doppler as an additional diagnostic aid may help the clinician in the management of pelvic masses. Further research is needed to clarify sensitivity and specificity.

MR imaging of the ovaries: normal appearance and benign disease.

MR imaging enables a physician to make an accurate diagnosis of various benign adnexal masses and helps to obviate unnecessary surgery.

New developments in the sonographic assessment of ovarian, uterine, and breast vascularity.

Recent developments in ultrasound have presented new opportunities for assessing tissue vascularity and blood flow with ultrasound. These new methods include 3D imaging, power Doppler sonography, a variety of harmonic imaging techniques, ultrasound contrast agents, electronic compounding, and pulse sequencing methods that improve the signal-to-noise relationship as well as structural conspicuity. By using these technological advances, it is now possible to assess macroscopic blood flow in organs and tumors, and to assess changes in flow and vascularity that occur in response to therapeutic efforts. This review article describes and illustrates the concepts and methods used to evaluate vascularity and blood flow in tissues with ultrasound. It describes some of the potential clinical applications of these new techniques in the ovary, uterus, endometrium, adnexal vessels, and breast.

The assessment of normal and abnormal luteal function by transvaginal color Doppler sonography.

OBJECTIVE: To evaluate intraovarian resistance index (RI) in 47 healthy fertile volunteers with ovulatory cycles, 28 patients with luteal phase defect (LPD) and four patients with luteinized unruptured follicle (LUF Sy). STUDY DESIGN: Transvaginal color Doppler assessment of the follicular and corpus luteum blood flow and plasma progesterone (P) levels were obtained in each patient. RESULTS: Significantly higher intraovarian artery RI (< 0.001) was obtained for LPD group than for controls during the luteal phase. In the control group both follicular and corpus luteum RI were significantly lower (P < 0.001) on the dominant side, while in LPD group no difference (P > 0.05) between the sides occurred. Mean P levels were significantly lower (P < 0.001) in the LPD group (6.9 +/- 2.3 ng/ml) than in controls (24.1 +/- 11.4 ng/ml). In all the LPD patients histopathology revealed delayed endometrial pattern, while normal endometrial dating was found in all the evaluated patients form the control group (n = 15). In the patients with LUF Sy (n = 4) similar RI values were obtained in the follicular and corpus luteum phase. There was no difference between the sides in terms of the intraovarian RI, while subnormal values of P were obtained in all the examined patients (14.1 +/- 6.2 ng/ml). CONCLUSIONS: Transvaginal color Doppler may predict the function capacity of the corpus luteum.

Cost-benefit analysis of laparoscopic versus laparotomy salpingo-oophorectomy for benign tubo-ovarian disease.

STUDY OBJECTIVE: To compare laparoscopy and laparotomy adnexectomy with respect to operating time, complications, length of hospitalization, convalescence, effectiveness, and surgical and equipment cost. DESIGN: A comparison of 30 consecutive patients undergoing laparoscopic adnexectomy from January 1990 to July 1991, and 27 consecutive patients who underwent adnexectomy by laparotomy from January 1985 to December 1990. SETTING: Private practice of one surgeon (GAV), and Department of Obstetrics and Gynecology, Lawson Research Institute, St. Joseph's Health Care Center, London, Ontario, Canada. PATIENTS: All patients had had a hysterectomy with preservation of at least one adnexa. The indications for adnexectomy were chronic pelvic pain or adnexal mass less than 6 cm diameter, with benign characteristics defined by sonography and tumor markers. INTERVENTIONS: Laparoscopic adnexectomy was performed by three-puncture technique with bipolar coagulation and endoloop ligation of the pedicle. Dissection and resection were performed with the carbon dioxide laser or scissors. RESULTS: Differences were noted between laparoscopy and laparotomy (mean +/- SD) in operating time (90 +/- 40 vs 65 + 20 min, p < 0.01), complications (11% vs 18.5%, p < 0.05), effectiveness (72% vs 72%), length of hospitalization (1.7 +/- 1.0 vs 7.1 +/- 1.2 days, p < 0.05), convalescence (2.2 +/- 1.7 vs 9.5 +/- 5.2 wks, p < 0.05), surgical cost ($1603 vs $5158), and equipment cost ($198,048 vs $17,345). CONCLUSIONS: Operating time, complications, safety, efficiency, and effectiveness were comparable for the two procedures. Markedly reduced hospitalization in the laparoscopy group resulted in a mean saving per patient of $3555. These women also had shorter convalescence and earlier return to normal activities and employment. The cost of laparoscopic equipment appears prohibitive, but it pays for itself after 50 surgical procedures.

Serial assessment of adnexal masses with transvaginal color Doppler sonography.

Transvaginal color Doppler sonography (TV-CDS) was performed on 64 women with adnexal masses at 3, 6 and 12 weeks after initial presentation. In 47 (72% of patients studied), the pelvic mass demonstrated a decrease in size and increase in pulsatility index (PI) after 12 weeks. Of the patients undergoing surgery in this group, one had a tubo-ovarian abscess, one diverticular abscess and one hydrosalpinx. In seven patients (10%), there was no change in size or PI. Three in this group had an endometrioma, whereas two had a peritoneal cyst. In five (7%), there was no change in size and an increase in PI. One of these patients had a mucinous cystadenoma. In three (5%), there was a decrease in size and PI. Two of these patients had a tubo-ovarian abscess. In two (3%) patients studied, the mass showed an increase in size and decrease in PI; both had corpora luteum cysts with acute hemorrhage. Seventy-two percent of masses with high impedance underwent regression, whereas only 21% of lesions with low impedance did. Only 20% of masses demonstrating low impedance or morphologically complex structure regressed. Sixty-five percent of lesions that regressed had a significant drop in PI, whereas all the lesions that showed no change in size or enlargement had either no change or decrease in PI. Probability of regression was the greatest in young women (less than 40 years of age) and in masses < 5 cm. Ninety-three percent of women with persistent masses that underwent progestational suppression demonstrated regression with decrease of PI and peak systolic velocity.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessment of the empty follicle syndrome by transvaginal sonography.

The empty follicle syndrome was assessed using transvaginal ultrasonography in a group of 152 consecutive women with unmedicated menstrual cycles being studied because of primary or secondary infertility or repetitive miscarriage. The overall frequency of the empty follicle syndrome was found to be 43.4%. The frequency increased with age but was independent of gravidity. The empty follicle syndrome may be a significant etiologic factor in infertility or other reproductive abnormalities, and transvaginal ultrasound represents a good, non-invasive means of evaluating it.

Assessment of ovarian tumor vascularity with transvaginal color Doppler sonography.

This report describes the results of transvaginal color Doppler sonography (TV-CDS) of 43 surgically proved ovarian masses. Waveform analyses of the signals arising from specific vessels (i.e., peripheral, central, septal) adjacent to and within these masses were correlated to those seen on macroscopic pathologic evaluation. The mean and standard deviation of the pulsatility indices (PI) of 32 benign lesions (1.8 +/- 0.8) were higher than 11 malignant ones (0.8 +/- 0.6) (P = 0.03). However, the range of benign (4.0 to 0.7) and malignant (1.5 to 0.4) lesions did overlap. Low PIs (less than 1.0) were found in five relatively benign lesions (one case each of dermoid cyst, cystadenoma containing a dermoid cyst, endometrioma, benign sclerosing stromal tumor, and thecoma), but also in all 11 malignant or borderline malignant lesions (nine cystadenocarcinomas, two germ cell tumors), causing an overlap between the PIs of some benign and malignant masses. With a 100% negative predictive value, our preliminary data suggest that TV-CDS can effectively exclude malignancy. However, with a positive predictive value of 73%, one in four malignant lesions diagnosed by TV-CDS will be benign.