High risk and low prevalence diseases: Tubo-ovarian abscess.

INTRODUCTION: Tubo-ovarian abscess (TOA) is a rare but serious condition that carries with it a high rate of morbidity and even mortality. OBJECTIVE: This review highlights the pearls and pitfalls of TOA, including diagnosis, initial resuscitation, and management in the emergency department (ED) based on current evidence. DISCUSSION: TOA is associated with pelvic inflammatory disease (PID) as well as intrauterine devices, uterine procedures, multiple sexual partners, diabetes mellitus, and immunocompromised states. While usually arising from a gynecologic infection, TOA can be associated with a gastrointestinal source. History and physical examination are limited, demonstrating predominantly lower abdominal pain, but a minority of patients will present with vaginal symptoms. Half of patients will exhibit systemic illness to include fever, nausea, and vomiting. Laboratory evaluation may reveal elevations in white blood cell count and other inflammatory markers. Transvaginal ultrasound and computed tomography (CT) may be utilized for diagnosis, though CT has higher sensitivity and can differentiate this disease from similarly presenting gastrointestinal pathology. Initial medical management includes antibiotics. Surgical intervention is indicated in those who fail initial medical therapy, which is more likely in those with bilateral abscesses, large abscesses, and older patients. CONCLUSIONS: An understanding of TOA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Transvaginal hydrolaparoscopy versus hysterosalpingography in the work-up for subfertility: a randomized controlled trial.

RESEARCH QUESTION: Is transvaginal hydrolaparoscopy (THL) non-inferior to hysterosalpingography (HSG) as a first-line tubal patency test in subfertile women in predicting the chance of conception leading to live birth? DESIGN: A multicentre, randomized controlled trial in four teaching hospitals in the Netherlands, which randomized subfertile women scheduled for tubal patency testing to either THL or HSG as a first-line tubal patency test. The primary outcome was conception leading to live birth within 24 months after randomization. RESULTS: A total of 149 women were randomized to THL and 151 to HSG. From the intention-to-treat population, 83 women from the THL group (58.5%) conceived and delivered a live born child within 24 months after randomization compared with 82 women (55.4%) in the HSG group (difference 3.0%, 95% CI -8.3 to 14.4). Time to conception leading to live birth was not statistically different between groups. Miscarriage occurred in 16 (11.3%) women in the THL group, versus 20 (13.5%) women in the HSG group (RR = 0.66, 95% CI 0.34 to 1.32, P = 0.237), and multiple pregnancies occurred in 12 (8.4%) women in the THL group compared with 19 (12.8%) women in the HSG group (RR = 0.84, 95% CI 0.46 to 1.55, P = 0.58). Ectopic pregnancy was diagnosed in two women in the HSG group (1.4%) and none in the THL group (P = 0.499). CONCLUSION: In a preselected group of subfertile women with a low risk of tubal pathology, use of THL was not inferior to HSG as a first-line test for predicting conception leading to live birth.

Bilateral sactosalphinx and congenital adrenal hyperplasia: case report on two rare conditions in two virgin girls.

BACKGROUND: Sactosalpinx means a collection of fluid (serum, blood or pus) in the fallopian tube. CAH (Congenital Adrenal Hyperplasia) is a typical 46XX DSD (Disorder of Sex Development) due to a steroidogenic enzymatic defect. Both conditions are rare and can lead to reduced fertility rate. CASE PRESENTATION: We describe two post-menarche virgin girls with CAH who were hospitalized for acute abdomen due to laparoscopically confirmed sactosalpinx. Case 1 recovered after conservative management, case 2 after a second-look and bilateral salpingectomy. The first case consisted of right sactosalpinx and previous peritonitis reported; the second one of bilateral symptomatic pyosalpinx and previous vaginal stenosis. Recurrent abdominal pain persisted at follow-up in Case 1: post-operative MRI (Magnetic Resonance Imaging) showed bilateral hydrosapinx that disappeared at a following ultrasound scan control. Follow-up was uneventful 36 months after surgery in Case 2, except for the surgical revision of the vaginal introitus. CONCLUSIONS: CAH-sactosalpinx association is a very rare but not negligible event. We suggest a conservative approach for sactosalpinx if tubal and/or ovary torsion can be excluded. Pyosalpinx is more challenging to treat, but during pediatric age we suggest starting with a conservative approach, especially in patients with CAH who have a potential low fertility rate. Careful gynecological follow-up after menarche is recommended to rule out any further causes of infertility.

Interventional Radiologist's Approach to Fallopian Tube Recanalization.

Fallopian tube obstruction (FTO) is a common cause of female infertility. In the setting of proximal FTO, fallopian tube recanalization (FTR) is a minimally invasive, ambulatory procedure with a technical success rate of up to 100%, with minimal postprocedural adverse events. One-year pregnancy rate following FTR is approximately 41%, with successful delivery of full-term infants in 84% of pregnancies. This minimally invasive, outpatient, image-guided procedure is an alternative to vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) and should be top-of-mind in the setting of infertility due to proximal FTO.

Clinical characteristics, treatment status and complications in women with tube ovarian abscess and endometriosis: a retrospective study.

BACKGROUND: The aim of our present study was to investigate the clinical characteristics, treatment status and complications in women with endometriosis (EM) and tube ovarian abscess (TOA) to determine the possible association between TOA and EM. METHODS: Medical records were used to analyze the clinical characteristics, treatment and complications. Twenty women who were diagnosed with TOA with EM were compared with 93 women diagnosed as having TOA without EM between January, 2008 and December, 2018. RESULTS: In this study, TOA patients with EM were significantly more likely to have a lower age range (20-39 years) than the non-EM group [11/20 (55.0%) vs 27/93 (29.0%)]. In addition, TOA patients with EM were associated with a significantly lower rate of parity [11/20 (55.0%) vs 75/93 (80.6%)], higher rates of infertility [8/20(40%) vs 0/93(0%)] and a significantly lower incidence of elevated blood platelet counts [5/20 (25%) vs 43/93 (46.2%)]. Furthermore, women with EM had greater blood loss (347 ± 445.77 vs 204.67 ± 289.46) and an increased complication rate [3/20(15%) vs 0/93(0%)]. Among the 3 patients who had complications in the EM group, 2 patients had septic shock and 1 patient had intestinal obstruction. And 1 case who had septic shock followed by IVF treatment. There was no significance difference on other factors. CONCLUSIONS: The present study indicated that EM did not increase the difficulty and time of treatment in patients with TOA, but increased bleeding during surgery and serious complications. It is suggested that doctors should pay more attention to postoperative treatment and nursing in women with TOA and EM, especially those who have a history of recent infertility treatment and related procedures.

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve. DATA SOURCES: Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve." METHODS OF STUDY SELECTION: All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English. TABULATION, INTEGRATION, AND RESULTS: Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery. CONCLUSIONS: The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

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.

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.

Comparison of the efficacy between bilateral proximal tubal occlusion and total salpingectomy on ovarian reserve and the cholinergic system: an experimental study

Background and aim: To compare the effects of bilateral proximal tubal occlusion and bilateral total salpingectomy on ovarian reserve and the cholinergic system via rat experiment. Materials and methods: Twenty-one adult female rats were randomly divided into the following three groups:G1 (n = 7), sham group;G2 (n = 7), bilateral total salpingectomy group; and G3 (n = 7), bilateral proximal tubal occlusion group. Four weeks later, the abdomen of the rats was opened. The right ovarian tissues were stored in 10% formaldehyde, whereas the left ovarian tissues were stored at ­80 °C in aluminum foil. Serum samples were evaluated for antimullerian hormone. The right ovary was used for histological and immunoreactive examination, and the left ovary was used for tissue MDA analysis. Tissue samples were analyzed for MDA levels with spectrophotometric measurement, apoptosis with TUNEL staining, fibrosis score with Mason trichrome staining, ovarian reserve with HE staining, and cholinergic receptor muscarinic 1 (CHRM1) level with immunoreactivity method. Results: Compared to G1 and G3, the number of corpus luteum with secondary follicles was significantly lower in G2, whereas the number of ovarian cysts and fibrosis and apoptosis scores increased significantly. The CHRM1 immunoreactivity was significantly lower in G2 than in G1 and G3. Conclusions: Compared to the bilateral proximal tubal occlusion performed by using bipolar cautery, bilateral total salpingectomy in rats leads to a significant damage in ovarian histopathology and the cholinergic system.

Tubo-Ovarian Abscesses: Epidemiology and Predictors for Failed Response to Medical Management in an Asian Population.

Pelvic inflammatory disease (PID) complicated by tubo-ovarian abscesses (TOA) has long-term sequelae in women of reproductive age. Consensus on the optimal treatment of TOA remains lacking. Most clinicians utilize antibiotics as a first-line conservative approach, failing which invasive intervention is adopted. Our aim is to identify risk factors predicting failed response to conservative medical management for TOA in an Asian population. A retrospective cohort study of 136 patients admitted to a tertiary hospital in Singapore for TOA between July 2013 and December 2017 was performed. Patients were classified into 2 groups: successful medical treatment with intravenous antibiotics and failed medical treatment requiring invasive intervention. 111 (81.6%) of patients were successfully treated with conservative medical approach using intravenous antibiotics; 25 (18.4%) required invasive intervention having failed medical therapy. Multivariate logistic regression model adjusted for age, ethnicity, C-reactive Protein (CRP), TOA size, and body mass index (BMI) showed the odds ratio (OR) of each centimetre increase in TOA size to be 1.28 (95% confidence interval (CI) 1.03-1.61; P=0.030) and every kg/m2 increase in BMI to be 1.10 (95% CI 1.00-1.21; P=0.040). Failed medical management was predicted by a cutoff of TOA size ≥ 7.4 cm and ≥ BMI 24.9 kg/m2. Patients who failed medical treatment received a mean of 4.0±2.1 days of antibiotics before a decision for invasive intervention was made, with a significantly longer intravenous antibiotic duration (9.4±4.3 versus 3.6±2.2 days; P <0.001) and prolonged hospitalization (10.8± 3.6 versus 4.5 ± 2.0 days; P <0.001) compared to the medical group. Patients with higher BMI and larger TOA size were associated with failed response to conservative medical management in our study population. Early identification of these patients for failed medical therapy is imperative for timely invasive intervention to avoid prolonged hospitalization, antibiotic usage, and patient morbidity.

Ozone therapy: a potential therapeutic adjunct for improving female reproductive health.

Ozone is emerging as a new adjunct therapeutic agent for female infertility. We here present a review of the literature, to date, pertaining to the effect of ozone therapy on tubal, ovarian, endometrial, and vaginal factors that could potentially affect female fertility. It also presents data pertaining to the relationship of ozone therapy on pelvic adhesion formation. Most data were performed on animals and very few human studies existed in the literature. Results suggested that ozone therapy could have beneficial effect on tubal occlusion, could protect from endometritis and vaginitis, might protect ovaries from ischemia and oocyte loss and finally might lead to less formation of pelvic adhesions. There is a critical need for human studies pertaining to ozone therapy, especially using safe methods of administration, such as transdermally or intravaginally, on female fertility.

Fallopian tube subtle pathology.

The aim of the present review is to give a comprehensive overview of fallopian subtle lesions and suggest the impacts of these abnormalities on fertility. Tubal subtle variations, including tubal diverticula, Morgagni hydatids, accessory fallopian tube, accessory ostium of the fallopian tube, tubal phimosis, agglutination, and sacculation, have been described and cited as making significant contributions to infertility. This review summarizes characteristics of these subtle abnormalities and provides an update of recent knowledge of the diagnosis and management of these variations. We hope that the present contribution may help to bring more attention to the clinical field to recognize these abnormalities and consequently aid in improving fertility.

Effect of nano-particles on MHD flow of tangent hyperbolic fluid in a ciliated tube: an application to fallopian tube.

This study shows the effects of magnetic field and copper nanoparticles on the flow of tangent hyperbolic fluid (blood) through a ciliated tube (fallopian tube). The present study will be very helpful for those patients who are facing blood clotting in fallopian tube that may cause for infertility or cancer. The nanoparticles and magnetic field are very helpful to break the clots in blood flowing in fallopian tube. Since blood flows in fallopian tube due to ciliary movement, therefore medicines containing copper nanoparticles and magnetic field with radiation therapy help to improve the patient. Ciliary movement has a particular pattern of motion i.e., metachronal wavy motion which helps to fluid flow. For the forced convective MHD flow of tangent hyperbolic nano-fluid, momentum and energy equations are solved by the small Reynolds' number approximation and Adomian decomposition method by constructing the recursive relation of ADM and solved by software "MATHEMATICA". The effects of parameters such as nanoparticle volume fraction, Hartmann number, entropy generation and Bejan's number have been discussed through graphs plotted in software "MATHEMATICA". It is found that blood flow is accelerated and heat transfer enhancement is maximum in the presence of nano particles, also magnetic effects accelerates the blood flow and help to enhance the heat transfer whereas the presence of porous medium increases the fluid's velocity and reduce the transfer of heat through fluid flow.

Vegetable fibre in an infected ovarian dermoid cyst.

Tubo-ovarian abscesses (TOAs) are inflammatory masses involving the fallopian tube, ovary and occasionally other adjacent pelvic organs. A 32-year-old woman with no significant medical history presented with a chief complaint of lower abdominal pain. Initial CT of the abdomen was suggestive of a colon abscess; however, a repeat CT suggested a TOA. The left ovary was densely adherent to the left pelvic sidewall and the rectosigmoid colon. The content of the ovary was consistent with a dermoid and suspected of superinfection. Pathological examination of the tissue revealed normal ovarian cortical tissue, hair cells, melanin, and epidermal and neural tissue, as well as evidence of a foreign object resembling vegetable matter. The vegetable fibre found in this patient's biopsy was of an unclear aetiology, but probably indicates a perforation of the bowel. Any cause of bowel perforation adjacent to the adnexa can lead to TOA, therefore providing a rational speculation for this case.

[Management of tubo-ovarian abscesses and complicated pelvic inflammatory disease: CNGOF and SPILF Pelvic Inflammatory Diseases Guidelines]. / Prise en charge des abcès tubo-ovariens (ATO) et des formes compliquées d'infections génitales hautes. RPC infections génitales hautes CNGOF et SPILF.

A tubo-ovarian abscess (ATO) should be suspected in a context of pelvic inflammatory disease (PID) in case of severe pain associated with the presence of general signs and palpation of an adnexal mass at pelvic examination. Imaging allows most often a rapid diagnosis, by ultrasound or CT, the latter being irradiant but also allowing to consider the differential diagnoses (digestive or urinary diseases) in case of pelvic pain. MRI, non-irradiating examination, whenever it is feasible, provides relevant information, more efficient, guiding quickly the diagnosis. The diagnosis of tubo-ovarian abscess should lead to the hospitalization of the patient, the collection of bacteriological samples, the initiation of a probabilistic antibiotherapy associated with drainage of the purulent collection. In severe septic forms (generalized peritonitis, septic shock), surgery (laparoscopy or laparotomy) keeps its place. In other situations, ultrasound-guided trans-vaginal puncture in the absence of major hemostasis disorders or severe sepsis is a less morbid alternative to surgery and provides high rates of cure. Today, ultrasound-guided trans-vaginal puncture has been satisfactory evaluated in the literature and is part of a logic of therapeutic de-escalation. Randomized trials evaluating laparoscopic drainage versus radiological drainage should be able to answer, in the coming years, questions that are still outstanding (impact on chronic pelvic pain, fertility). The recommendations for the management of ATO published in 2012 by the CNGOF remain valid, legitimizing the place of radiological drainage associated with antibiotic therapy.

The effectiveness of neutrophil to lymphocyte ratio in prediction of medical treatment failure for tubo-ovarian abscess.

AIM: We aimed to compare the neutrophil-to-lymphocyte ratio (NLR) in tubo-ovarian abscess (TOA) patients who responded to medical treatment or who underwent surgical intervention due to medical treatment failure. METHODS: The files of the patients, hospitalized in our Obstetrics and Gynecology Department with TOA diagnosis between August 2015 and December 2017, were evaluated retrospectively. The conservative management group was comprised of 38 of the 81 patients (46.9%) who responded to sole medical treatment with the triple antibiotic regimen (gentamicin-clindamycin-ampicillin) and the surgical intervention group was comprised of 43 patients (53.1%) who did not respond to medical treatment and needed further surgery and/or interventional radiologic abscess drainage. Demographic and clinical data, imaging findings, and laboratory results including NLR were compared between two groups. RESULTS: There were statistically significant differences between the groups in terms of age, TOA diameter, white blood cell and neutrophil counts, and NLR levels (P < 0.05). The mean NLR was 7.4 ± 5.8 for the conservative management group and 10.3 ± 5.8 for the surgical intervention group (P = 0.004). The area under the curve (AUC) for NLR was 0.69 (threshold value was ≥6.97, 95% confidence interval, sensitivity 79.1%, specificity 57.9%). On multiple regression analysis, a significant correlation was identified between age, NLR and resistance to the medical treatment. CONCLUSION: Neutrophil-to-lymphocyte ratio and age are significantly higher in patients with medical treatment failure and NLR could be used as a novel marker in addition to white blood cell in the prediction of medical treatment failure in TOA patients.

Conservative management for postmenopausal women with tubo-ovarian abscess.

OBJECTIVES: The aim of the study was to describe the experience of one institution in management and outcome of tubo-ovarian abscess (TOA) in pre- and postmenopausal women and to reassess the optimal approach for TOA in postmenopausal women. METHODS: A retrospective cohort study included women diagnosed with TOA between 2003 and 2017 in a tertiary referral center. TOA was diagnosed by sonography or computerized tomography and at least one of the following criteria: temperature more than 38°C, leukocytosis more than 15,000 mm, or surgically proven disease. Women were followed up for a mean of 7.6 years (range 6 mo to 14 y). The rates of conservative management and pelvic malignancy were evaluated. RESULTS: The study cohort included 144 (69.23%) women who met the inclusion criteria, of which 105 (72.92%) were premenopausal and 39 (27.08%) were postmenopausal. Univariate analysis found no differences in risk factors and disease characteristics between the two groups. Among the study sample, 22 (56.4%) postmenopausal women and 48 (45.7%) premenopausal women were treated surgically (P = 0.5). None of the premenopausal women and 1 (2.6%) postmenopausal woman were diagnosed with pelvic malignancy. CONCLUSION: In postmenopausal women with TOA, the prevalence of concurrent pelvic malignancy was 2.6%, which is higher than in the general population, but lower than that reported in the literature; 44% were conservatively managed without any apparent cases of misdiagnoses of cancer.