Ovarian Drilling in PCOS: Is it Really Useful?

Polycystic ovary syndrome (PCOS) is a frequent disorder, affecting approximately 5-10% of infertile women. It can represent more than 80% of cases of infertility due to anovulation. The main goal of treatment is the induction of mono-ovulatory cycles. A pragmatic management of infertility in PCOS will allow most patients to conceive. Weight loss and clomiphene citrate (CC) are the first-line components of patients treatment before gonadotrophins are used. However, during gonadotrophin administration, there is a high risk of ovarian hyper-stimulation and multiple pregnancies. So, surgery with laparoscopic ovarian drilling is often used before gonadotrophins in order to obtain normal ovulatory cycles.

[Medical treatment of ectopic pregnancy]. / Traitement médical de la grossesse extra-utérine.

BACKGROUND: The ectopic pregnancy (EP) is a public health problem and its frequency has doubled in most industrialized countries in 20 years. aim: To evaluate the effectiveness of medical treatment of ectopic pregnancy with methotrexate (MTX) intramuscularly (IM). METHODS: prospective study supported between October 2006 and December 2010. The selected patients received methotrexate IM (1 mg per kg). The monitoring was based on: the kinetics of plasma HCG, clinical examination and ultrasound. A second injection was performed if hCG on day 4 was increased by more than 25% or J7> the initial rate. Healing corresponded to obtain a zero rate of HCG in a stable manner. RESULTS: We used the first-line medical treatment in 122 patients. The average age of patients was 31.94 years. A haematosalpinx was found in 87.70% of cases. The initial rate of HCG plasma varied between 40 IU/ml and 4088 IU / ml, with an average of 805.88 m IU / ml. The primary success rate obtained after a single injection of intramuscular MTX was 67%. The high success rate obtained after two injections of MTX was 27%. The overall success rate after 1 or 2 injections of MTX was 82%. 17 patients underwent surgical treatment after a first injection of methotrexate. 5 patients underwent surgery after receiving two doses of methotrexate. The period of normalization of plasma levels of h CG was 24 days on average, with extremes ranging from 4 to 43 days for 67 patients cured after a single injection of MTX. This period was 33 days on average, with extremes ranging from 8 to 62 days for patients healed after two injections of MTX. CONCLUSION: Medical treatment applied to 38% of ectopic pregnancies diagnosed in our department is effective in 82% of cases if the inclusion criteria are strictly adhered to. Successful treatment is limited by patient compliance and demanding nature of monitoring.

[Postmenopausal bleeding. Comparison between ultrasonography, hysteroscopy and histology results]. / Les métrorragies post ménopausiques. Confrontation des résultats échographiques, hystéroscopiques et histologiques.

BACKGROUND: Post-menopausal bleeding are frequently found in gynaecological consultations and requires the search of an organic cause AIM: To value the profit and the performances of the transvaginal ultrasonography and the hysteroscopy in the determination of the causes of post-menopausal bleeding. METHODS: 80 patients presenting abnormal uterine bleeding in post menopause period have been explored in our department with transvaginal ultrasonography and hysteroscopy. The findings have been evaluated on the basis of specimens obtained from either endometrial biopsy, hysterectomy or operative hysteroscopy. We have calculated in our study the sensitivity, the specificity, the positive and negative predictive values of transvaginal ultrasonography and hysteroscopy. RESULTS: The sensitivity, the specificity, the positive and negative values predictive of the transvaginal ultrasonography is respectively 93, 75%, 87, 5%, 83, 3% and 95, 45%. In the other part, hysteroscopy seems more performant in the diagnosis of intrauterine abnormalities with the respective values: 100%, 95, 83%, 94, 11% and 100%. CONCLUSION: The initial investigation in front of all mennorhagic patients must be the transvaginal ultrasonography but we also need the hysteroscopy because its highly accurate means in the diagnosis of the causes of excessive uterine bleeding in post menopausal period.

[Correlation between vital signs and hemoperitoneum in ruptured ectopic pregnancy]. / Corrélation entre signes vitaux et hémopéritoine au cours des grossesses extra-utérines rompues.

BACKGROUND: Ectopic pregnancy (EP) is a medical-surgical emergency. Rupture of an ectopic pregnancy is a serious complication and may develop severe life-threatening to the patient. AIM: To determine correlation between vital signs and hemoperitoneum in ruptured ectopic pregnancy and the association between abnormal vital signs and tubal rupture. METHODS: Via a retrospective study we have considered a sample of 32 patients of ruptured ectopic pregnancy. All patients were diagnosed at the Gynecology and Obstetrics Unit Aat Charles Nicole Hospital, Tunisia. RESULTS: Mean minimum systolic (SBP) 109 mmHg (range 70-150), mean maximum (HR) 81.5 beats/min (range 70-140). Mean volume of hemoperitoneum 693.75 mL (range 100 -2000 mL).Correlation between vital signs and volume of hemoperitoneum was poor (R 2 = 0.279 for HR, R 2= 0.267 for SBP). Hypotension was associated with blood loss of at least 1280 ml. Association of tachycardia with hypotension was observed in only 2 cases.Correlation between HR and SBP was not significant and poor (p=0.23, R 2= 0.05) CONCLUSION: Normal vital signs alone are poor predictors of ruptured ectopic pregnancy and do not correlate well with volumes of hemoperitonieum.

[Sublingual Misoprostol for cervical ripening before diagnostic hysteroscopy: a randomized and prospective study about 108 cases]. / Préparation cervicale par misoprostol avant hystéroscopie diagnostique : etude prospective randomisée à propos de 108 cas

AIM: To evaluate the benefits of cervical preparation with 200 mcg of Misoprostol administered 2 hours before diagnostic hysteroscopy. METHODS: Prospective randomized and double-blind study. A total of 108 patients were randomized into two groups: The first group G1 of 54 patients who received 200 mcg Misoprostol sublingually, two hours before diagnostic hysteroscopy, and a control group of 54 G2 patients without prior preparation. The surgeons were not informed before each act to which group the patient belongs. The parameters analyzed were: the rate of patients requiring dilation to Hegar candle to introduce the hysteroscope, hysteroscopy complications, and the side effects of Misoprostol. RESULTS: In the Misoprostol group, 5 patients required the use of mechanical cervical dilatation (9.2%) against 12 patients (22.2%) in the control group. The average diameter of the larger candle used was 5.3 mm in the Misoprostol group against 4.2 mm in the control group. No significant difference was found between the two groups concerning the rate of complications in both procedures. By comparing the effect of Misoprostol in the group of postmenopausal women, no significant differences were observed regarding the use of cervical dilation or the rate of complications during hysteroscopy. Mor-over, no significant difference was observed in patients with a history of vaginal delivery. CONCLUSION: No significant difference was noted in this study between Misoprostol group and control group, despite less use of cervical dilation and less complications in Misoprostol group.

A case of cutaneous endometriosis developed on an abdominal scar.

BACKGROUND: Endometriosis is characterized by the presence of an ectopic endometrial tissue. It affects between 1% and 5% of women in reproductive age. Its main clinical symptoms are dysmenorrhoea and infertility. Among women having had abdominal surgery for any gynecological reason, the prevalence of endometriosis is between 15% and 50%. CASE REPORT: We report the case of a 15 year-old patient who underwent surgery twice : once for appendicitis two years before and once for acute salpingitis and tubo-ovarian abscesses one year before. Laparotomy was performed by Pfannenstiel incision. The post operative course was uneventful. The patient reported the gradual emergence of two bluish nodes on the abdominal scar. These nodules became painful and turgid during the menstrual period. She also reported the issue of blood from the abdominal scar during menstruation. The abdominal examination, performed during the menstrual period, showed a scar of good quality and two regular shiny and bluish cutaneous nodules measuring 1 cm in size. These elements were firm and painless. An endometriosis node on the scar of laparotomy was suspected. Surgery was performed in order to remove both nodules. At surgery the depth of nodules reached the top of the abdominal fascia of the major rights. The content of these nodules was chocolate brown. The histo-pathological examination confirmed that these nodules contained ectopic endometrial tissue. CONCLUSION: The etiopathogeny of endometriosis is still a subject of debate. This case illustrates the possibility of occurrence of endometriosis on abdominal scars after laparotomy: an unusual location.

Ovarian abscess as a complication of assisted reproduction techniques: a case report.

BACKGROUND: AMP makes true great strides these last decades. Logically some complications were noticed even due to ovarian puncture such as hemorrhage, perforation or infection. The aim of this report is to try, through a review of literature, to draw the attention of physicians to a rare entity, ovarian abscess after follicle aspiration for in-vitro fertilization, and to means of prevention. CASE REPORT: We report a 38-year-old woman who was plainting from lower abdominal pain located in the left iliac fossa one month after failed IVF trial. The pain was associated with fever and vomiting. The patient's past medical history involves 2 myomectomys (2003-2007). On admission, her temperature was 38.9 degrees C and her blood pressure was 90/60 mm Hg. Physical examination found nondistended abdomen. Tenderness to deep palpation in the left lower quadrant, without peritoneal signs, was detected. No masses were palpated. Mild tenderness in the left cul-de-sac was found. A full blood count showed a white cell count of 17,500 cells/mm3 with 84.5% polymorph nuclear cells, CRP 173 mg/dl. Pelvic ultrasound shows a left latero uterine mass; right ovary and the uterus are unremarkable; there was no free abdominal fluid. The laparotomy was performed 24 hours later and a left ovarian abscess was found. The treatment was conservative. Antibiotics were associated during 15 days. The clinical evolution was satisfying. CONCLUSION: The ovarian puncture might be technically difficult, incomplete, and even impossible which exposes to a greater infection risk. An ultrasound evaluation of ovarian accessibility is necessary before starting an IVF attempt, especially in case of overweight or history of abdominal or pelvic surgery, endometriosis, tubal abnormalities or myomas. The treatment is based on surgery and antibiotics.

[Imperforate hymen: a series of 13 cases]. / Imperforation hyménéale: A propos de 13 cas.

BACKGROUND: Imperforate hymen is a rare congenital malformation. Patients often remain asymptomatic until puberty and present in early adolescence with cyclic abdominal pain. Early diagnosis and treatment must be performed in order to prevent morbidity. THE AIM of this study was to asses management of this disease. METHODS: A retrospective study of 13 cases of imporforate hymen diagnosed in the department of obstetrics and gynecology "A" of Charles Nicolle hospital of Tunis from January 1980 to December 2008. The clinical features and the management are discussed. RESULTS: The mean age was 14 years. All patients were single and had primary amenorrhea. They presented with pelvic pain in 9 cases and bladder urinary retention in 4 cases. Secondary sexual characters were present and normal in all cases. Inspection of the vulva could establish the diagnosis in all cases. Pelvic ultrasounds showed the hematocolpos in all cases. The latter was associated to a hematometria and a Douglas pouch liquid in 2 cases. Hematocolpos was evacuated by hymeneotomy under oxytocin infusion in all cases. Eight patients were treated by cruciform incisions and five patients were treated by radial incisions of the hymen. The volume of hematocolpos varied from 250 ml to 2000 ml. One patient underwent surgery twice for restenosis of the imperforate hymen. CONCLUSION: Imperforate hymen is a rare anomaly. Its diagnosis is simple and could be established at birth by a systematic screening. More frequently, the diagnosis must be suspected in front of a primary amenorrhea associated to abdominal pain in order to prevent complications.

[Benign ovarian tumors during pregnancy. A review of 26 cases]. / Tumeurs de l'ovaire au cours de la grossesse: a propos de 26 cas.

OBJECTIVE: To identify the particularities of ovarian tumors during pregnancy. METHODS: A retrospective study of 26 patients who underwent surgical treatment for ovarian tumors during pregnancy between January 1993 and December 2005. Clinical, ultrasonographic, therapeutic and histological data were analysed. RESULTS: The mean age of patients was 26.5 years. The circumstances under which the ovarian tumors were discovered consisted of adnexal torsion in 57% of cases, chronic pelvic pain in 15% of cases and at routine ultrasonographic scan in 26% of cases. 20 patients underwent cystectomy by laparotomy and 4 patients underwent laparoscopic cystectomy. 3 patients underwent adnexectomy. One abortion occurs 2 days after an adnexectomy. 17 deliveries occur at term. Histological findings were functional cyst in 4 cases, serous cyst in 11 cases, mucinous cyst in 2 cases and dermoid cyst in 7 cases. CONCLUSION: Ovarian tumors during pregnancy are rare. They are usually serous, functional and dermoid cysts. Laparoscopic ovarian cystectomy offers significant advantages with respect to laparotomy for the pregnant patient.

46 XY pure gonadal dysgenesis with gonadoblastoma and dysgerminoma.

BACKGROUND: Swyer syndrome is a distinct type of pure gonadal dysgenesis characterized by a 46 XY karyotype in female phenotypic patients. It shows an abnormality in testicular differentiation. It is usually revealed by primary amenorrhea. The tumor that usually develops in Swyer syndrome is gonadoblastoma. Although gonadoblastoma is considered benign, the risk of malignant germ cell tumor development is high. OBJECTIVE: The aim of this report is to stress on the risk of occurrence of malignant germ cell tumors on these dysgenesic gonads. CASE REPORT: We present the clinical, sonographic and endocrine findings in the case of a 13 year-old phenotypic young girl with a 46 XY karyotype and gonadal dysgenesis. The patient underwent surgery for adnexal torsion. An examination of the gonads revealed gonadoblastoma associated to dysgerminoma. The treatment and the follow up are detailed. CONCLUSION: The presence of Y chromosome in the karyotype of a patient presenting a gonadal dysgenesis must lead to prophylactic bilateral gonadectomy in order to avoid a malignant transformation. Gonadectomy must be followed by a hormone replacement therapy.