The added benefit of transvaginal sonography in the clinical staging of cervical carcinoma.

INTRODUCTION: Patients diagnosed with cervical cancer face several treatment options, depending on the physical examination and the imaging modality results. Transvaginal sonography (TVS) was proposed as an imaging option to determine local spread of cervical tumors, along with magnetic resonance imaging, also by recently released International Federation of Gynecology and Obstetrics recommendations. We examined whether combined data from physical examination, high-detail TVS, and positron emission tomography with 18 F-labeled fluoro-2-deoxyglucose and computed tomography (18 F-FDG PET/CT) may contribute to triage efficiency of cervical cancer patients. MATERIAL AND METHODS: This is a retrospective study of consecutive women diagnosed with cervical cancer at the Carmel Health Center, Haifa, Israel, during 2010-2015. Inclusion criteria were histology of cervical cancer and the availability of three modalities-a thorough physical examination, a high-detail TVS, and positron emission tomography (PET) with 18 F-FDG and computed tomography (18 F-FDG PET/CT). End points were the possibility to predict local invasion to the parametrium and distant lymph node metastasis at the time of triage to surgery or chemoradiation. RESULTS: Seventy-three patients with cervical cancer were evaluated. TVS correctly predicted no involvement of the parametrium for the 25 who had a postoperative pathological report. TVS measurement of tumor dimension was also matched by the pathological report in these cases. Only three patients were referred for adjuvant therapy according to postoperative pathology criteria. Among 43 women treated with a combination of chemotherapy and radiotherapy due to advanced disease, and with complete data, at least two modalities were congruent with chemoradiation for 33 (77%). Three patients (7%) were referred to chemoradiation due to TVS result alone. CONCLUSIONS: The combination of high-detail TVS, directed to predict tumor dimensions and local spread, performed by a trained operator, combined with 18 F-FDG PET/CT and physical examination, can assist in selecting optimal treatment for cervical cancer patients, thus avoiding unnecessary operations.

Clinical Use and Optimal Cutoff Value of Ca15-3 in Evaluation of Adnexal Mass: Retrospective Cohort Study and Review of the Literature.

OBJECTIVE: To estimate the diagnostic performance and reference values of serum cancer antigen (Ca)15-3 levels in the triage of adnexal masses. MATERIALS AND METHODS: This retrospective cohort study was carried out in 481 patients referred to the Gynecology Department at Carmel Medical Center due to adnexal mass between years 2005 and 2012. All patients underwent surgery with histopathologically confirmed diagnosis and routine preoperative measurements of serum Ca125 and Ca15-3. RESULTS: Combination of Ca125 with Ca15-3 elevated the sensitivity of Ca125 alone (from 86.9% to 93.2%; P=0.029), along with reduction of its specificity (from 80.5% to 69.5%; P=0.005) in differentiation between malignant and benign cases. According to receiver operating characteristic curve, Ca15-3 level of 21 U/mL was shown to be the optimal reference value for malignancy detection. All cases with Ca15-3 levels above 44.5 U/mL were malignant, mostly of primary ovarian source. CONCLUSIONS: As Ca15-3 assessment allowed detection of significantly more malignancy cases, we believe that measurement of this marker in combination with Ca125 is worthwhile in patients presenting with adnexal masses. The cutoff of 21 U/mL seems to be the optimal value in this specific population. High Ca15-3 levels (above 44.5 U/mL) strongly direct to a diagnosis of malignancy, mostly of primary ovarian tumors rather than breast malignancy.

Should the Risk of Invasive Cancer in Pregnancy and the Safety of Loop Electrosurgical Excision Procedure During the First 15 Weeks Change Our Practice?

OBJECTIVE: The aim of this article was to describe the outcome of women diagnosed with cervical intraepithelial neoplasia (CIN) grades 2 or 3 in pregnancy either observed or treated by loop electrosurgical excision procedure (LEEP) in the first 15 weeks of gestation. METHODS: Loop electrosurgical excision procedure during the first 15 gestational weeks compared with observation of CIN2/3. This is a retrospective analysis of a nonrandomized study at tertiary, academic, and referring centers in Israel. Ninety-three pregnant women diagnosed with CIN2/3 between 2006 and 2016 were included in this study. Fifty patients with CIN2/3 on cervical biopsy were conservatively followed-up, and 43 patients have undergone LEEP during the first 15 gestational weeks. Main outcome measures were ultimate diagnosis of invasive cancer or CIN, pregnancy outcome, and complications. RESULTS: In 5.4% of CIN2/3 during pregnancy, the final diagnosis was invasive cancer. The postpartum results of 50 women who were conservatively observed were as follows: 3 (6.0%) had cervical cancer and undergone radical hysterectomy, 33 (66.6%) had CIN2/3, and 14 (28%) had CIN1 or normal histology. The diagnoses of the 43 patients who have undergone LEEP were invasive cancer in 2 patients (4.6%) but did not undergo hysterectomy, CIN2/3 or adenocarcinoma in situ (AIS) in 38 patients (88.4%), and 3 women (7%) had CIN1 or normal histology. None of them suffered severe bleeding. Thirty-seven women continued their pregnancy, 34 (91.9%) had term deliveries, 2 (5.4%) gave birth at 34 and 36 weeks, and 1 patient had missed abortion (2.7%). CONCLUSIONS: The LEEP procedure during the first 15 weeks of pregnancy is safe. A total of 5.4% of the women with CIN2/3 during pregnancy were diagnosed with invasive cancer. It is time to reconsider the recommendations about CIN2/3 in early gestation.

Oxidative markers in cryopreservation medium from frozen-thawed embryos: a possible tool for improved embryo selection in in vitro fertilization?

PURPOSE: The present study evaluated the association between oxidative parameters in embryo cryopreservation medium and laboratory and clinical outcomes. METHODS: This prospective laboratory study was conducted in an IVF unit in a university-affiliated hospital with 91 IVF patients undergoing a frozen-thawed embryo transfer cycle. Following thawing, 50 µL of embryo cryopreservation medium was retrieved from each cryotube and tested by the thermochemiluminescence (TCL) assay. TCL amplitudes after 50 (H1), 150 (H2), and 280 s (H3) were recorded in counts per second (CPS) and the TCL ratio determined for comparison with implantation and pregnancy rates. RESULTS: A total of 194 embryos were transferred in 85 frozen-thaw cycles. Twenty-one pregnancies (24.7 %) occurred. Implantation and overall and clinical pregnancy rates were higher when the median TCL H1 amplitude was <32 CPS compared to ≥32 CPS (14.6 vs. 5.3 %, 37.5 vs. 17 %, 28.1 vs. 9.4 %, respectively). No pregnancies occurred when the H1 amplitude was ≥40 CPS. Logistic regression multivariate analysis found that only the median TCL H1 amplitude was associated with the occurrence of pregnancy (OR = 2.93, 95 % CI 1.065-8.08). The TCL ratio inversely correlated with the duration of embryo cryopreservation (r = -0.37). CONCLUSIONS: The results indicate that thawed embryos may express oxidative processes in the cryopreservation medium, and higher oxidative levels are associated with lower implantation rates. These findings may aid in the improved selection of frozen-thawed embryos for IVF.

CEA in evaluation of adnexal mass: retrospective cohort analysis and review of the literature.

BACKGROUND: The aim of this study was to estimate the diagnostic accuracy of serum carcinoembryonic antigen (CEA) levels in conjunction with Ca125 in the triage of adnexal masses. METHODS: This retrospective cohort study was carried out in 495 patients referred to the Gynecology Department at Carmel Medical Center due to adnexal mass, between 2005 and 2012. All patients underwent surgery with histopathologically confirmed diagnosis and preoperative measurements of serum Ca125 and CEA. For each marker, sensitivity, specificity, positive predictive value, negative predictive value and risk ratio were calculated. RESULTS: Combination of CEA with Ca125, compared with Ca125 levels alone, yielded a nonsignificant effect on sensitivity (87.4% vs. 88.9%, respectively, p = 0.64) and specificity (79.3% vs. 74.3%, p = 0.18) in differentiating malignant from benign adnexal masses. CEA levels were higher in mucinous histological types, but were not helpful in detection of borderline tumors. Significantly higher CEA (21.4 ± 53.6 vs. 3.2 ± 11.9 ng/mL, p = 0.0002) and lower Ca125 values (103.9 ± 84.9 vs. 796 ± 1,331.5 U/mL, p = 0.0338) were demonstrated in the 17 metastatic cases compared with 181 primary ovarian malignancies. CONCLUSIONS: The combination of the tumor markers CEA and Ca125 did not contribute significantly to the detection of malignant adnexal masses compared with Ca125 alone. As our results suggest that higher CEA levels could be useful in differentiating metastatic tumors from primary ovarian malignancy and in diagnosis of mucinous histology, this issue should be investigated in large, well-designed, prospective cohort trials.

CA 19-9 in evaluation of adnexal mass: retrospective cohort analysis and review of the literature.

OBJECTIVE: The aim of this study was to estimate the diagnostic accuracy of serum marker CA 19-9 levels in the triage of adnexal masses. METHODS: This retrospective cohort study was carried out in patients referred to the Gynecology Department at Carmel Medical Center due to adnexal masses. All patients underwent preoperative measurements of serum CA 125 and CA 19-9 and surgery with histopathologically confirmed diagnosis. RESULTS: Between January 2005 and December 2012, 503 patients with adnexal masses were evaluated with serum tumor markers. Combination of CA 19-9 with CA 125, compared with CA 125 levels alone, suggested a nonsignificant effect on sensitivity (86.9% vs. 88.9%, respectively, p = 0.54) or specificity (79.5% vs. 73.5%, p = 0.1) in differentiating malignant from benign adnexal masses. CA 19-9 was not helpful in detecting mucinous histological types or borderline tumors. Mean CA 19-9 levels were higher in metastatic cases compared with primary ovarian malignancy (488.7 ± 1,457 vs. 46.3 ± 149.8 U/mL, respectively, p = 0.001). In mature cystic teratomas, mean CA 19-9 levels were higher and CA 125 levels were lower than in ovarian carcinoma (p = 0.049 and p = 0.0012, respectively). CONCLUSIONS: The combination of the tumor markers CA 19-9 and CA 125 did not contribute significantly to the detection of malignant adnexal masses compared with CA 125 alone. As our results suggest that higher CA 19-9 levels could be helpful in differentiating metastatic tumors from primary ovarian malignancy; this issue should be investigated in large well-designed prospective cohort trials.

The quality of periconception medical care in women with diabetes needs improvement.

OBJECTIVE: We evaluated the quality of periconception medical care in pregnant women with diabetes and assessed the influence of sociodemographic characteristics. RESEARCH DESIGN AND METHODS: The study was based on retrospective data collection from electronic database on cohort of Israeli women at Clalit Health Services (CHS) with pre-existing diabetes who gave birth in 2008-2011. It included data on A1C and other laboratory test results, prescription fillings, diet and ophthalmology consultations, and sociodemographics extracted from CHS computerized systems. The performance of each of nine recommended measures in the periconception period and a composite quality score was evaluated; the score ranged from 0-8. Multivariate logistic regression was used to examine independent sociodemographic predictors of low-quality overall scores. RESULTS: A total of 166 women gave birth to 180 infants; the performance of the different quality parameters ranged from 81% for A1C and kidney function tests to only 30% for dietary consultation and 41.1% for ophthalmology exam. Forty-nine percent of women had A1C <7.0% (53 mmol/mol). Only 45% took folic acid, whereas 13.9% continued the use of potentially teratogenic drugs in the first trimester. One-third of women were in the low-quality (0-3) overall score. In the multiple logistic regression analysis, the only significant variables to predict lower composite quality scores were multiparity odds ratio of 3.43 (95% CI 1.66-7.10; P = 0.001), Arabian ethnicity 3.76 (1.78-7.92; P = 0.001), and immigrant 3.73 (1.25-11.16; P = 0.018). CONCLUSIONS: The periconception medical care of diabetic women is suboptimal. More intensive and targeted care is needed in order to optimize periconception care of diabetic patients, especially in the high-risk subpopulations.

Quality of medical care in diabetic women undergoing fertility treatment: we should do better!

OBJECTIVE: Diabetic women are at increased risk for adverse pregnancy outcomes that can be improved by preconception care. Our goal was to evaluate the quality of medical care in diabetic women who undergo fertility treatment and compare it with the quality of medical care in diabetic women with spontaneous pregnancies. RESEARCH DESIGN AND METHODS: This retrospective study on reproductive-age women undergoing fertility treatment in Clalit Health Services (CHS) used data on fertility treatments, prescription fillings, HbA(1c) levels, and demographics extracted from CHS computerized systems. The control group comprised women with spontaneous pregnancy. Three quality measures in the periconception period were evaluated: folic acid prescription fillings, evaluation and level of HbA(1c), and use of potentially hazardous drugs. RESULTS: There were 230 fertility treatment cycles in 83 diabetic women, and 30 diabetic women had spontaneous pregnancy. Women in the fertility group were older and had fewer children. There were no significant differences in marital status or ethnicity. Regular folic acid use, HbA(1c) recording, and the percentage of women with HbA(1c) <7% was similar between women in fertility treatment and those with spontaneous pregnancy (23.9, 57.8, and 31.3% vs. 20.0, 73.3, and 40.0%, respectively). Several women in both groups continued the use of potentially hazardous medication. CONCLUSIONS: The periconception medical care of diabetic women who undergo fertility treatment is suboptimal and no better than that of diabetic women with spontaneous pregnancies. More intensive and targeted counseling regarding the importance of folic acid and glycemic control is needed to optimize periconception care of these diabetic patients.

[Oxidation and female reproduction: the good, the bad and what's between].

Reactive oxygen and nitrogen species constitute an inseparable part of aerobic life on earth. They have been known to science for about 90 years, but only during the last 50 years research in this field has expanded. Initially, scientists focused on the free radicals-induced damage to biological systems. Since the eighties, a new concept has emerged, namely, that alongside the oxidative stress-induced deleterious effect and its association with a variety of diseases, a certain threshold level of oxidation is essential to intracellular signaL transduction. Recently, some data has accumulated regarding the involvement of oxidative processes in various aspects of female reproduction, including ovarian function, fertilization, early development of the embryo and implantation. Nevertheless, there is still a long way before comprehensive and thorough understanding of their role, both at the molecular level and the expression in the clinical setup of fertility patients can be achieved. In this article, we shall address some molecular biochemical processes involved in the activity of free radicals, and review the present knowledge regarding their role in female fertility, including ovarian physiology, follicular and oocyte maturation, development of the early embryo and implantation, as well as their association with reproductive pathologies such as endometriosis, polycystic ovary disease and recurrent pregnancy loss.

Normal fasting plasma glucose levels during pregnancy: a hospital-based study.

OBJECTIVE: Recently, the International Association of Diabetes and Pregnancy Study Groups have suggested new criteria for the diagnosis of gestational diabetes including a fasting glucose level of ≥92 mg/dL. We determined reference levels for normal fasting plasma glucose levels throughout pregnancy and evaluated the new normal cut-off for fasting glucose level. METHODS: Charts of patients who delivered in our hospital between June 2001 and June 2006 were reviewed. Women with pregestational diabetes, fasting glucose level >105 mg/dL or delivery at <24 weeks were excluded. Fasting glucose levels were assessed in 11 time categories between three months prior and four months postpartum in 7946 women. RESULTS: Compared to preconception levels, fasting glucose levels decreased by a median of 3 mg/dL in the first trimester (81-78 mg/dL). During the third trimester a slight further glucose reduction was observed (median 76 mg/dL). After delivery fasting glucose levels increased sharply (84 mg/dL in the puerperium and 81 mg/dL by three months postpartum). Throughout pregnancy 5.2-9.0% of pregnant women had a fasting glucose level of ≥92 mg/dL [compared to 8.2% in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study]. CONCLUSION: Fasting glucose levels decrease early in pregnancy with only slight further decrease later on. It seems that the same fasting glucose cut-off can be used throughout pregnancy for the diagnosis of gestational diabetes mellitus.

The effect of paternal age on assisted reproduction outcome.

OBJECTIVE: To summarize the current knowledge about the association between paternal age and assisted reproductive technology (ART) outcomes. In contrast to the extensive investigation of the relationship between maternal age and the success of ART, there are few studies examining the effect of paternal age on ART outcomes. DESIGN: Systematic review of the literature. By means of a PubMed literature search using the phrases "paternal age", "male age", and "assisted reproductive technology", we identified articles that investigated the role of male age in in vitro reproduction techniques. RESULT(S): The 10 studies included in this review did not show a clear correlation between advanced paternal age and rates of fertilization, implantation, pregnancy, miscarriage, and live birth. Paternal age was not found to affect embryo quality at the cleavage stage (days 2-3). However, a significant decrease in blastocyst embryo formation was associated with increased paternal age, probably reflecting male genomic activation within the embryo. Except for volume, characteristics of semen such as motility, concentration, and morphology did not decrease with age. CONCLUSION(S): There is insufficient evidence to demonstrate an unfavorable effect of paternal age on ART outcomes. Further study with well-defined entry criteria and uniform reporting of outcomes is needed to investigate the subject.

Pregestational body mass index, weight gain during pregnancy and maternal hyperglycemia.

OBJECTIVE: To evaluate the associations between pregestational BMI and weight gain during pregnancy and the risk for maternal hyperglycemia. METHODS: The charts of all patients who delivered at our hospital between June 2001 and June 2006 were reviewed. Maternal hyperglycemia categories were defined as GDM (by the Carpenter and Coustan criteria); Impaired glucose tolerance (IGT - only one abnormal value in the 100 g OGTT); Abnormal GCT (≥140 mg/dL) but no high values on the OGTT. Women with GCT < 140 were defined as normal glucose tolerance (NGT). RESULTS: Pregravid BMI and glucose tolerance data were available for 9269 women. We also had data on weight gain during pregnancy for 7766 of these women. There was strong graded association between increasing BMI category and all levels of maternal hyperglycemia. There was significant negative correlation between BMI and weight gain during pregnancy (R = -0.251, P value < 0.0001). However, in the multivariate logistic regression model, only pregestational BMI was significantly associated with maternal hyperglycemia, whereas weight gain during pregnancy was no longer significant. CONCLUSIONS: Obesity is a strong predictor for gestational maternal hyperglycemia. Weight gain during pregnancy has less effect. Every effort should be made for pregestational weight reduction in overweight women.

[Medical treatment of diabetic patients in high risk pregnancy clinic improves glycemic control prior to fertility treatment].

INTRODUCTION: Diabetic women are at increased risk for spontaneous abortions and congenital anomalies. Preconception care can improve pregnancy outcome. AIM: To evaluate glycemic control in diabetic women undergoing fertility treatment, and compare between women who were treated in high risk pregnancy (HRP) clinics prior to fertility treatment and those who received usuaL care. METHODS: Retrospective study on diabetic women undergoing fertility treatment during 2008-2009 in Haifa and Western Galilee District of Clalit Health Services (CHS). Data on fertility treatments, prescription fillings, HBA1C Levels and demographic data was extracted from CHS computer Data on medical treatment in HRP clinic was retrieved from visits in the researcher clinic. We evaluated measurement and Level of HBA1C within 3 months of fertility treatment; and compared it between the two groups. RESULTS: There were 230 fertility treatment cycles in 83 diabetic women; 10 women were treated in the HRP clinic. Median HBA C was significantly lower 6.1% in the HRP group compared to 7.1% in women who received usual care (P < 0.05]. HBA1C Level was recorded within 3 months of fertility treatment in 84.2% of cycles in the HRP group compared to 52.6% of cycles in the usual care group (P < 0.05). Furthermore, HBA1C < 7.0% was found in 68.4% of cycles in women in the HRP clinic compared to only 24.0% of cycles in the other group [P < 0.05). CONCLUSIONS: The medical care of diabetic women undergoing fertility treatment needs improvement. Many women undergo fertility treatment despite poor glycemic control. Referral to HRP clinic improves diabetic control and can improve pregnancy outcome.

[Human papillomavirus types in women with cervical cancer in Haifa District].

BACKGROUND: Human papillomavirus (HPV) is recognized as the absolute cause of cervical cancer and is found in 99% of the Lesions. HPV 16 and 18 are detected in 70% of the cases. Two vaccines against HPV 16 and 18 were approved for use in Israel in recent years. PURPOSE: To determine the prevalence of human papillomavirus (HPV) in women with invasive cervical cancer in the Haifa district, and to see if the vaccine is suitable for our population. METHODS: The study population included 65 women from the Haifa District who were diagnosed with invasive cervical cancer in the Cervix Clinic of Carmel Medical Center. Samples for HPV typing were obtained during the evaluation of those patients. DNA was extracted from brush samples and HPV genotype was determined by nested-PCR followed by sequencing. RESULTS: Out of 65 patients with cervical carcinoma, 64 were found positive for HPV. The main HPV types in our patients were HPV 16 in 53.8% of the patients, HPV 18 in 12.3% of the patients and HPV type 45 in 13.8% of the patients. HPV type 33 was found in 4.6% of the patients, and HPV types 31 and 66 in 3.1% of the patients. Each of HPV types 54, 56, 58 and 59 were found in one patient. The main complaint was postmenopausal bleeding or menometrorrhagia in 24 patients (36.9%), post coital bleeding in 18 patients (27.7%) and 14 patients (21.5%) were evaluated due to an abnormal cytological smear Squamous cell carcinoma was diagnosed in 83% of the patients and cervical adenocarcinoma in 15.1% of them. CONCLUSIONS: The prevalence of HPV types in Haifa district is similar to world prevalence of HPV's, where HPV 16 and 18 cause 66.1% of cervical cancer, while in our study HPV45 and HPV 66 were found in higher proportions of cases than reported worldwide. In our population the vaccine against HPV 16/18 can prevent almost 70% of cases of cervical cancer, but a multicenter study should be performed in order to obtain larger numbers.

Urodynamic findings in women with pelvic organ prolapse and obstructive voiding symptoms.

OBJECTIVE: To determine whether obstructive voiding symptoms in women with advanced pelvic organ prolapse (POP) were associated with objective bladder outflow tract obstruction. METHODS: We reviewed preoperative data from patients with advanced POP who underwent surgical correction at the Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel, between December 1, 2005, and November 30, 2007. Obstructive voiding symptoms were recorded from Pelvic Floor Distress Inventory-20 questionnaires. RESULTS: Of the 81 women aged 44-80 years who were included in the study, 40 (49.4%) reported incomplete bladder emptying preoperatively. There was no significant difference between these women and asymptomatic women in terms of demographic and clinical parameters such as age, parity, and stage of prolapse. Furthermore, there was no significant difference with regard to postvoid residual bladder volume (52.8 ± 65.8 vs 41.6 ± 41.2 mL), maximal (23.8 ± 11 vs 21.9 ± 9.6 mL/second) and average (10.3 ± 6.2 vs 9.3 ± 4 mL/second) urinary flow velocities, prevalence of increased postvoid residual volume (10.0% vs 4.8%), or obstructive urinary flow (17.5% vs 7.3%). CONCLUSION: Almost half of all women with advanced POP experienced incomplete bladder emptying; however, this symptom did not correlate with objective urodynamic bladder outflow tract obstruction.

Displacement of ureteral orifices following anterior colporrhaphy.

INTRODUCTION AND HYPOTHESIS: It is currently unknown whether ureteral orifices maintain their anatomic location after reconstructive pelvic surgeries. We therefore aimed to assess ureteral orifices' location after anterior colporrhaphy. METHODS: Between August and December 2007, patients undergoing anterior colporrhaphy for advanced cystocele in our institution underwent cystoscopy with intravenous dye injection and placement of ureteral catheters before and after the surgery. Each ureteral orifice location was marked on an X-Y coordinate on the posterior bladder wall before and after surgery. RESULTS: Thirteen women aged 44-80 years were included in the study. Postoperatively, ureteral orifices were noted to migrate 0.65 +/- 0.3 cm caudally (closer to the urethrovesical junction) (p = 0.002) and 0.32 +/- 0.5 cm laterally (p < 0.05). CONCLUSIONS: Anterior colporrhaphy is associated with significant caudal and lateral displacement of both ureteral orifices. These findings are of potential importance for pelvic reconstructive surgeons and may facilitate faster cystoscopic evaluation of ureteral patency postoperatively. They may also have implications on the angle of the preferred optical equipment to be used.

[Post hysterectomy vaginal vault prolapse: diagnosis prevention and treatment].

Post-hysterectomy vaginal vault prolapse is a common disorder which generally manifests as a protrusion of the vagina through the genital hiatus, sometimes accompanied by urinary and gastrointestinal symptoms as well as sexual dysfunction. Risk factors for this condition include vaginal deliveries, obesity and previous hysterectomy, although genetic predisposition leading to reduced connective tissue and muscle strength may also play a role. Surgical correction of this disorder can be performed through either the abdominal or transvaginal approaches. Two prospective randomized trials have compared these approaches demonstrating better anatomic success rates for the abdominal approach as opposed to faster recovery and lower morbidity for the transvaginal approach. Laparoscopic and other transvaginal minimal access techniques for vaginal vault suspension have recently been advocated utilizing synthetic or biological adjuvant grafts. These techniques have been associated with high success rates albeit substantial graft complications such as erosion, contraction and dyspareunia. Suspension of the vaginal apex to the uterosacral ligaments (McCall culdoplasty) or to the sacrospinous ligaments at the time of vaginal hysterectomy is the mainstay for prevention of post hysterectomy vaginal vault prolapse. Our knowledge of the pathophysiology of post hysterectomy vaginal vault prolapse is quickly being refined, leading to more efficient surgical therapies for prevention and treatment of this disorder.

Primary repair of advanced obstetric anal sphincter tears: should it be performed by the overlapping sphincteroplasty technique?

Advanced obstetric anal sphincter tears are often associated with a high incidence of fecal and flatus incontinence. We aimed to assess the clinical outcome of these repairs when done by the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. Between August 2005 and December 2006, all grades 3 and 4 obstetric anal sphincter tears in our department were repaired by a reconstructive pelvic surgeon, primarily using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum. All women were followed every 6 months using the Colorectal Anal Distress Inventory and Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire, a physical examination of the anal sphincter, anal manometry, and transperineal anal sonography. There were 3,478 deliveries of which 22 (0.63%) anal sphincter tears were repaired in women aged 22-41 years. Two women were diagnosed with Royal College of Obstetricians and Gynecologists grade 3a, eight with grade 3b, nine with grade 3c, and three with grade 4 anal sphincter tears. Postoperatively, 21 patients attended the outpatient clinic, with an average follow-up time of 9.2+/-1.4 months. Only two women (9.5%) complained of flatus incontinence and fecal urgency and had mildly decreased anal sphincter squeeze pressure and a small sonographic anal sphincter defect. None of the women complained of fecal incontinence. Two women (9.5%) reported on transient perineal pain and one (4.8%) on transient dyspareunia. All other women were asymptomatic and had normal anal manometry and sonographic evaluation. Repair of obstetric anal sphincter tears using the overlapping sphincteroplasty technique with reconstruction of the internal anal sphincter and perineum seems to carry favorable clinical outcome and reduced risk for anal incontinence, perineal pain, and sexual dysfunction.

Preconception care--when and what: the attitude of Israeli gynaecologists to preconception counseling.

OBJECTIVES: Preconception care is a form of preventive care and its implementation might improve general women's health as well as improving pregnancy outcome. Our aim was to survey the attitudes of Israeli gynecologists regarding preconception counseling. METHODS: E-mailed questionnaires were sent to gynecologists in an Israeli gynecology network. The questionnaire included two identical sets of questions; one was regarding the care of reproductive aged women who visit their gynecologist for various reasons and the second was regarding the care of women in their first prenatal visit. Answers were scored (from 3-always to 0-never), summed and compared using Chi-square and paired t tests. RESULTS: Mean score for the preconception set was significantly lower than the prenatal set 11.3 (62.7%) versus 16.9 (93.7%) respectively, P < 0.001. Folic acid supplementation and genetic screening tests were recommended to most women in 99 and 94% of first prenatal care visit compared to only 42 and 62% of women who were not pregnant (P < 0.001). CONCLUSIONS: Gynecologists fail to recognize proper opportunities for preconception care. Increased awareness and concrete guidelines concerning timing and content of preconception counseling might be helpful.