Role of ultrasonographic parameters for predicting tubal involvement in infertile patients affected by endometriosis: A retrospective cohort study.

INTRODUCTION: Transvaginal ultrasound is fundamental for the mapping of endometriosis, and the imaging criteria have been clearly described for different organs study. However, no specific ultrasonographic signs of tubal endometriosis have been reported, with the exception of hydrosalpinx, which is the expression of an extreme tubal damage and obstruction. The detection of tubal pathology in infertile patients is fundamental, therefore the aim of the study was to evaluate incidence of tubal endometriosis in infertile patients, and to analyze ultrasonographic signs useful for detection of this condition. MATERIAL AND METHODS: It is a single-center, retrospective cohort study. All 500 consecutive infertile women who underwent laparoscopic surgery for endometriosis were included. The preoperative workup included transvaginal ultrasound and was compared to intraoperative findings and histologic study. RESULTS: The incidence of tubal endometriosis in our study was 8%. Using hydrosalpinx as the ultrasonographic marker for tubal involvement the overall pooled, sensitivity and specificity of TVU were 12% (95%CI, 5-23%) and 99% (95%CI, 98-100%), respectively. If at least one ultrasonographic parameter like hydrosalpinx, periadnexal adhesions or ovarian cyst was considered as a sign of tubal endometriosis, a sensitivity, VPN and specificity were 94% (95% IC, 85-98%), 97% (95%IC, 93-99%) and 31% (95%CI, 27-36%), respectively. DISCUSSION: Hydrosalpinx as ultrasonographic sign alone is characterized by a high specificity but low sensitivity for detection of tubal endometriosis; its sensitivity can be improved by the addition of other markers such as endometrioma and/or periadnexal adhesions.

Tubo-Ovarian Abscess in Non-Sexually Active Adolescent Girls: A Case Series and Literature Review.

STUDY OBJECTIVE: We investigated risk factors and common causes of tubo-ovarian abscess (TOA) in non-sexually active females in order to aid in earlier diagnosis, treatment, and improved outcomes. DESIGN: This is a retrospective observational case series of all non-sexually active females younger than age 25 years who were diagnosed with TOA. Review of the existing literature was also performed. SETTING: Academic tertiary care children's hospital. PARTICIPANTS: Ten patients meeting study inclusion criteria were identified for the study, and 33 other patients were identified in the literature. RESULTS: Average age at time of diagnosis was 14 years. Average body mass index was 24 kg/m2. Most presented with abdominal pain, often associated with fevers, nausea, vomiting, and diarrhea. Seven of 10 patients were treated surgically with pelvic washout (4 primarily and 3 after failing empiric antibiotic therapy). Most frequently, anaerobic gut flora were isolated on culture. All patients received broad-spectrum intravenous antibiotics, and were then discharged on a course of doxycycline and metronidazole or clindamycin. Three patients required additional admissions and multiple rounds of antibiotics due to persistent symptoms. The average length of stay was 3 days for patients treated with antibiotics only and 6 days for patients requiring surgical intervention. Six patients had complete resolution of symptoms and improvement on ultrasound within 2-4 weeks. The remainder were lost to follow-up. CONCLUSION: These cases, in conjunction with previous case reports, emphasize the importance of considering TOA in patients with concerning imaging or examination findings despite lack of sexual activity. Given the large proportion of cases attributable to anaerobic gut flora, treatment with antibiotics with adequate anaerobic coverage is recommended. Surgical drainage is not always necessary, but is often needed for diagnostic purposes or in patients not clinically improving with conservative measures.

Impact of early surgical management on tubo-ovarian abscesses.

This 5-year retrospective study aimed to investigate whether early surgical management improves outcomes in patients presenting with a tubo-ovarian abscess (TOA). Patient characteristics, investigation results and treatment outcomes were compared. 50 women were diagnosed with a TOA during the study period. Nineteen (38.0%) were treated with antibiotics (medical group) and thirty one (62.0%) were treated surgically on admission (early surgical group). The early surgical group was associated with a high success rate of 96.8% and the lowest risk of readmission within 12 months (16.1%). There was no significant difference in the length of stay between the early surgical and the successful medical group.Impact StatementWhat is already known on this subject? Tubo-ovarian abscess (TOA) is an inflammatory mass that forms most commonly as a complication of untreated pelvic inflammatory disease (PID). Traditionally, TOAs are treated first with broad-spectrum intra-venous antibiotics, with surgical intervention considered after 72 h. It is not known whether early surgical intervention would be beneficial to patient outcomes compared to traditional management.What do the results of this study add? In this study, we have demonstrated a high success rate with early surgical management. Readmission rate was lowest in the early surgical group compared to the medical and late surgical group. This suggests that early surgical intervention may be beneficial, compared to the standard management of trialling antibiotics and then proceeding to surgery 72 h later.What are the implications of these findings for clinical practice and/or further research? Our study suggests that early surgery may be beneficial in the management of TOAs. Although we were unable to demonstrate statistical significance, our data suggest that it would be worthwhile to investigate white blood cell (WBC) and C-reactive protein (CRP) further as a potential predictor for failure of medical management. In the future, more studies comparing early surgical management with medical and late surgical management could inform clinicians of the best mode of treatment for these patients.

Tubo-ovarian abscess in postmenopausal women: A systematic review.

PURPOSE: To evaluate and better characterize the incidence, clinical presentations and risk factors of TOA in postmenopausal women and to evaluate the incidence of underlying malignancy in postmenopausal women with TOA. METHODS: Electronic based search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, and Cochrane Central Register of Controlled Trials. The following medical subject heading (Mesh) terms, keywords, and their combinations were used: "tubo-ovarian abscess, pelvic inflammatory disease, menopausal and postmenopausal". RESULTS: Of 380 articles in the initial results, nine studies were eligible for inclusion in our systematic review. The prevalence of postmenopausal cases out of total TOA episodes was 6-18%. The most common risk factor identified was a recent pelvic procedure including endometrial biopsy in up to 45% of reported cases. A somewhat surprising risk factor was the presence or the act of removal of a longstanding intrauterine device (IUD), which was in place for many years, and was reported in up to 50% of cases. Recent studied showed that the risk of diagnosing a malignancy in postmenopausal women with TOA was lower than previously described. Attempts to identify patients with an underlying malignancy were unsuccessful, as neither size, complexity of the mass, bilateral lesions, tumor marker or lab work was sufficiently sensitive. CONCLUSIONS: TOA is not a frequent finding in postmenopausal women. Yet, it may lead to or mask significant morbidity or mortality. A somewhat surprising risk factor for TOA in postmenopausal women is the presence or following removal of a longstanding IUD. The risk of malignancy is lower than previously described.

Mucocele of the appendix presenting as an exacerbated chronic tubo-ovarian abscess: A case report and comprehensive review of the literature.

RATIONALE: Appendiceal mucocele is a rare entity of mucinous cystic dilatation of the appendix. It has no typical clinical presentation and is considered a potentially premalignant condition. PATIENT CONCERNS: We present a case of accidental intraoperative finding of an appendiceal mucocele in a 54-year old woman that clinically presented with an exacerbated chronic tubo-ovarian abscess. DIAGNOSES: Trans-vaginal ultrasonography showed an encapsulated, oval, unilocular mass above the uterus with a heteroechogenic structure, homogeneous fluid content, and smooth regular walls without inner proliferation. The histopathologic diagnosis was consistent with an appendiceal cystadenoma. INTERVENTIONS: The patient underwent a simple appendectomy. OUTCOMES: There were no clinical, biochemical or imaging signs of the disease recurrence at 6 months follow up. LESSONS: To our knowledge, this is the only well-documented case of appendiceal mucocele mimicking exacerbated chronic tubo-ovarian abscess reported in the literature. Awareness of a rare entity such as an appendiceal mucocele, which is frequently misdiagnosed as a potential cause of acute abdomen, is necessary for the appropriate management strategy in order to prevent complications.

Femoral hernia containing the right fallopian tube: chronic pain with menstruation.

Femoral hernias represent less than 10% of groin hernias and appear mainly in adult women; incarceration is more usual than in other hernias. Content found within the sac is commonly small bowel or omentum. Other anatomical structures, such as appendix, bladder, Meckel's diverticulum, ectopic testis, stomach and gynaecological organs are extremely unusual. A 48-year-old woman presented with intense right groin pain over 48 hours. Her past medical history revealed periodical moderate right groin pain coincident with her menstrual cycles, usually self-limited. No abdominal symptoms or fever were present. On physical examination, an incarcerated right femoral hernia was suspected. Subsequently abdominal ultrasound revealed a right femoral hernia containing an echogenic structure with conserved vascularisation. The patient underwent an emergency surgery. During the procedure the right fallopian tube and several small cysts were discovered as the hernia sac contents. As no ischaemic signs were observed, and the sac was sutured and reduced. Femoral hernioplasty was accomplished with polypropylene mesh. The postoperative course was uneventful and the patient was discharged within 24 hours. After an exhaustive literature review, we have found few cases reporting the presence of fallopian tube in adult women with femoral hernia, but none described a recurrent groin pain coinciding with menstruation, as in this case.

The human tubal lavage proteome reveals biological processes that may govern the pathology of hydrosalpinx.

Hydrosalpinx, the blockage of fallopian tubes, can result from pelvic inflammatory disease. Hydrosalpinx is a cause of infertility and negatively impacts in vitro fertilization. To better understand the pathobiology of hydrosalpinx, we compared the proteome of lavages from disease vs. healthy fallopian tubes. Results indicate a disruption of redox homeostasis and activation of the complement system, immune cell infiltration, and phagocytosis; pathways that may drive tubal injury. To our surprise among the most prominent proteins with hydrosalpinx was mesothelin (MSLN), which until now has only been associated with epithelial malignancies. Analogous to mesothelioma and ovarian carcinoma, a significant increase of MSLN was detected in plasma from patients with hydrosalpinx. This finding suggests MSLN may provide clinical diagnosis in lieu of the current approaches that require invasive imaging. Importantly, these findings implicate MSLN in a benign disease, indicating that the activation and role of MSLN is not restricted to cancer.

Endometriosis III and IV as a risk factor for tubal obstruction in infertile women.

OBJECTIVE: A previous study carried out among infertile women with tubal obstruction identified a relative risk of 2.5 for Chlamydia trachomatis seropositivity. However, endometriosis may also be associated with increased risk. This study aimed to evaluate the risk of tubal obstruction associated with endometriosis III/IV among women submitted to assisted reproductive procedures. METHODS: A case-control study was performed among 144 women with and without tubal obstruction. We calculated the odds ratio with 95% CI regarding the association of endometriosis III/IV and tubal obstruction. Calculations were performed using the SPSS v.17.0 package. RESULTS: The mean age was 33.7 years (4.76 SD), and the mean infertility duration time was 66.7 months (120.6 SD). The total prevalence of endometriosis was 20/144 (13%). Among 144 women, the risk group with tubal obstruction and endometriosis III/IV comprised 7out of 20 (35%), compared with the group without such risk, that comprised 22 out of 124 (17%). The X2 test was 3.19 with a p-value of 0.07. The odds ratio (OR) was 2.5 (95% CI: 0.647-9.639). CONCLUSION: Although the OR was 2.5, there was no significant difference between the groups with and without endometriosis III/IV. Further studies are needed to increase the sample size.

Ectopic varices masquerading as lower gastrointestinal bleeding.

A middle-aged woman previously in good health arrived to hospital with severe haemorrhagic shock. An abdominal and pelvic CT scan showed hepatomegaly, fluid in the sigmoid colon, perigastric and right sided pelvic varices without a clear source of bleeding. Urgent esophagogastroduodenoscopy excluded gastric varices and active upper gastrointestinal bleeding and the colonoscopy was inconclusive due to haemodynamic instability and massive bleeding which made it impossible to proceed with a full colonoscopy. An explorative laparotomy identified liver cirrhosis and bleeding from varices of the right fallopian tube which had formed a fistula with the caecum. A right hemicolectomy with a side to side anastomosis and a right sided salpingo-oophorectomy were carried out. The patient was thereafter transferred to the intensive care unit intubated, requiring massive fluid resuscitation and high doses of vasoactive agents. Nine days after hospital admission she was transferred to the surgical ward and followed up by a hepatologist.

Acute abdominal pain due to internal herniation of the sigmoid colon, fallopian tube and left ovary, a rare presentation of Allen Masters syndrome.

In 1955, Allen and Masters describe a painful syndrome which associates traumatic delivery to laceration found on the posterior leaf of the broad ligament. Herniation through this defect is a rare entity, accounted for about 4-7% of all internal hernias. Normally, it involves the small bowel. The authors present the case of a multiparous woman admitted at emergency for constipation and abdominal pain. The CT scan showed an extremely rare case of internal hernia of the sigmoid colon, fallopian tube and left ovary through a large defect of the broad ligament. The patient underwent a full laparoscopic surgery that allowed the reduction of the hernia and the suture of the defect with very good outcome.

Is genital tract infection related to tubal diseases in infertile Vietnamese women?

INTRODUCTION: The goal of this study was to identify the profile of genital tract infections and their relationship with clinical and demographic parameters as well as tubal diseases among infertile women in Vietnam. METHODOLOGY: In this cross-sectional descriptive study, we enrolled 597 women undergoing infertility treatment at the Center for Reproductive Endocrinology and Infertility, Hue University Hospital, Vietnam. All of the study participants were interviewed and examined by a gynecologist. Consecutive tests were then conducted including direct microscopy examination (wet mount and Gram stain), vaginal culture, polymerase chain reaction (PCR) for chlamydia diagnosis from a cervical canal swab, and a blood test for syphilis detection. A hysterosalpingogram (HSG) was carried out to examine the uterine cavity and Fallopian tubes. RESULTS: A gynecologic infection was diagnosed in 43.4% (259/597) of the infertile women. Bacterial vaginosis was the most common condition at 19.6%of the cases. Candida spp., Chlamydia trachomatis, and Trichomonas vaginalis infections accounted for 17.4%, 3.7%, and 0.3%, respectively. Normal HSG results accounted for 87.4% of the women while 5.5% had 2-sided tubal occlusions, 5.4% had 1-sided tubal occlusions, 1.0% had 1-sided hydrosalpinx, and 0.7% had 2-sided hydrosalpinx. There was no significant association between tubal diseases and current infections; however, aerobic vaginitis increased the risk of tubal diseases by 2.4 times. CONCLUSIONS: A marked proportion of infertile Vietnamese women have genital tract infections that can significantly influence their reproductive function and performance. These infections should be routinely screened and treated properly to prevent their consequences, such as infertility, which is especially important in developing countries.

Multidose Methotrexate Treatment of Ectopic Pregnancies with High initial ß-Human Chorionic Gonadotropin: Can Success Be Predicted?

OBJECTIVE: To investigate the clinical results and prognostic factors of multiple dose methotrexate (Mtx) treatment of ectopic pregnancy patients with high initial serum (human chorionic gonadotropin [hCG]). DESIGN: Retrospective cohort study. PATIENTS: Twenty-six ectopic pregnancy patients with serum (ßhCG) > 5,000 mIU/mL who received multiple doses of Mtx (1 mg/kg) with folinic acid rescue on the alternating days. RESULTS: Success rate was 88.5%. All failures were tubal ruptures in those who underwent surgery. Median initial hCG values of the success and the failure patients were 8,582 (5,058-31,114) and 5,280 (5,042-13,563) mIU/mL respectively (p > 0.05). Side effects were seen in 18 patients (69.2%, one bone marrow suppression and 17 minor side effects). The number of Mtx injections (7.04 ± 1.71), Mtx dose (71.35 ± 13.16 mg) and follow-up period (42.04 ± 23.77 days) did not differ between groups. Body mass index (BMI), Mtx dose, number of Mtx and change in ßhCG levels between the initials and the levels measured 2 days after the 3rd, 4th, and 5th Mtx injections were found to be highly predictive for tubal rupture. CONCLUSIONS: Multiple-dose Mtx treatment of ectopic pregnancies with high initial hCG is safe and effective. BMI, Mtx dose, number of Mtx injections and the decrement of ßhCG levels were found as highly predictive for the success of the treatment.

Use of etonogestrel implant beyond approved duration: prolonged contraceptive effectiveness.

BACKGROUND: The subdermal etonogestrel contraceptive implant has a current approved duration of 3 years. There is, however, recent and strong evidence of its effectiveness for 2 additional years during which no pregnancies were documented. CASE: We report a case of a 28-year-old woman who had an etonogestrel implant inserted 4 years earlier and wished to get pregnant. The implant was, however, deep in the triceps muscle and could not easily be removed. Her serum levels of etonogestrel remained positive even 6 years after insertion. As infertility investigation revealed endometriosis and bilateral tubal obstruction she was referred for assisted reproduction. Despite obtaining oocytes during an ovarian stimulation cycle, the endometrium was never above 4 mm, precluding embryo transfer. It was decided to remove the implant in order to improve endometrial conditions, after which the patient achieved pregnancy. CONCLUSION: This case report suggests that the etonogestrel implant is effective for even longer than the most recent studies have shown.

Uretero-fallopian fistula after hysteroscopy fallopian tube embolization: a case report.

BACKGROUND: Uretero-fallopian fistula (UFF) is a very rare surgery complication which usually happens after surgeries of fallopian tube or ureter. There has been no report of interventional operations of fallopian tube causing UFF. CASE PRESENTATION: A 41-year-old female received fallopian tube embolization for birth control. After that she noticed "clear vaginal discharge". She neglected that symptom for 7 years, until a sudden onset of abdominal pain brought her to the ER. Retrograde ureterogram confirmed UFF and revealed severe hydronephrosis of the left kidney. She received left nephrectomy afterwards and recovered well, with no urine leakage from her vagina. CONCLUSION: UFF could be caused by interventional operations of fallopian tube, and could lead to severe consequences. The application of fallopian tube embolization should be carefully controlled.

Persistent Vaginal Leakage in the Setting of an Apical Vaginal Sinus Tract: A Case Report.

Fistulas are defined as abnormal connections between 2 organ, vessels, or structures. They can often present in the genitourinary tract as a result of iatrogenic injury during pelvic surgery. A 46-year-old female presents many years after a hysterectomy for persistent vaginal leakage with concern for a vesicovaginal fistula. Computed tomography urogram, intravenous retrograde pyelogram, and cystoscopy were negative for vesicovaginal fistula; however, a vaginal sinus tract was noted and further explored. This case report will describe the use of both laparoscopy and concomitant vaginoscopy to diagnose and, ultimately, surgically excise a salpingovaginal fistula.

Serum procalcitonin levels together with clinical features and inflammatory markers in women with tubo-ovarian abscess for discriminating requirements for surgery for full recovery.

Tubo-ovarian abscess (TOA) coexists in 15% of cases with pelvic inflammatory disease. Medical treatment is the first line of approach in women with TOA, however, 25% of cases fail to respond to antibiotics, therefore, these cases need to undergo surgical intervention. We aimed to determine factors leading to failure of medical treatment in women diagnosed with TOA. According to our results among 144 women, 27 cases required surgical intervention for full recovery. None of the demographic, sonographic or laboratory findings, including procalcitonin level, had significant predictive value for the failure of medical treatment in women with TOA. Impact statement What is already known on this subject? Tubo-ovarian abscess (TOA) coexists in 15% of cases with pelvic inflammatory disease. Medical treatment is the first line approach in women with TOA, however, 25% of cases fail to respond to antibiotics, therefore, these cases need to undergo surgical intervention. Several risk factors have been evaluated in order to predict the failure of medical treatment. What do the results of this study add? None of the variables, including age, parity, mass diameter, serum CRP, procalcitonin levels and sedimentation rate had significant value for predicting TOA cases that required surgical intervention for full recovery. What are the implications of these findings for clinical practice and/or further research? In clinical practice, identification of risk factors leading to the failure of medical treatment helps clinicians to inform patients and help surgeons predict those who need surgical intervention.