A case of primary infertility and a patient with ventriculoperitoneal shunt.

Ventriculoperitoneal (VP) shunts are the main treatment modality for patients with hydrocephalus. The complications arising in patients with VP shunts are well documented. We present a case of infertility in a patient with a long-standing VP shunt. Her infertility is thought to be the result of pelvic adhesions due to factors related to the distal end of her VP shunt. A 22-year-old female with a 1-year history of infertility was referred due to bilateral hydrosalpinges. Diagnostic laparoscopy revealed multiple adhesions surrounding the distal end of the fallopian tubes. The distal portion of a VP shunt, which was placed over the course of her childhood, was found to be grossly inflamed and densely adherent to the pelvic viscera. VP shunts may produce abdominal adhesions and can cause mechanical infertility.

Adnexal torsion.

This review provides timely information concerning clinical, surgical, and pathologic findings of adnexal torsion (AT). AT mostly occurs in the child-bearing age group, but is not uncommon in premenarchal girls or postmenopausal women. When AT is suspected, urgent surgical intervention is indicated, and is usually performed by laparoscopy. Incidence of AT is 3.5% of all benign cystic teratomas. Despite the "necrotic" appearance of the twisted ischemic ovary, detorsion is the only procedure which should be performed at surgery. Adnexectomy should be avoided as ovarian function is preserved in 88% to 100% of cases. Awareness and suspicion of the diagnosis of AT is needed in patients who present with lower abdominal pain.

Parental karyotype and subsequent live births in recurrent miscarriage.

OBJECTIVE: To compare the subsequent live birth rate in recurrently miscarrying women with and without parental balanced chromosomal aberrations. DESIGN: Retrospective comparative cohort study. SETTING: Tertiary referral unit in a university hospital. PATIENT(S): Nine hundred sixteen patients with 3-16 miscarriages before 20 weeks: 99 patients with and 817 patients without chromosomal aberrations. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Outcome of the subsequent pregnancy in terms of live births or repeat miscarriage. RESULT(S): Of the 916 patients, 661 subsequently conceived, 73 (73.7%) with parental chromosomal aberrations and 588 (71.9%) without aberrations. In patients with and without chromosomal aberrations, 33 of 73 pregnancies (45.2%) and 325 of 588 pregnancies (55.3%), respectively, resulted in live births. The difference is not statistically significant. There was a similar prevalence of aberrations in primary, secondary, and tertiary aborters. The prevalence of aberrations was not related to the number of previous miscarriages. Translocations, inversions, and mosaicism were followed by a similar live birth rate. CONCLUSION(S): Patients with parental chromosomal rearrangements do not have a significantly lower live birth rate than patients without aberrations. Parental karyotyping might not be a good predictor of the outcome of subsequent pregnancies.

Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function.

BACKGROUND: Recently detorsion has replaced salpingo-oophorectomy as treatment for the twisted ischaemic adnexa. This paper asssess whether the ovary resumes normal function after preservation by detorsion. METHODS: The results of detorsion performed between January 1988 and December 2001 were retrospectively analysed. Post-operative complications and subsequent ovarian function were assessed including: ultrasound monitoring of follicular development, adnexal appearance during subsequent surgery, and the outcome of IVF. RESULTS: A total of 102 detorsions were performed; 67 by laparoscopy, 35 by laparotomy. No patient developed thromboembolism. Post-operative fever occurred in 15% of patients after laparoscopy and 29% after laparotomy (P < 0.01). Patients were hospitalized for a mean (+/- SD) of 2.1 +/- 1.2 and 7.4 +/- 1.5 days after laparoscopy and laparotomy respectively (P < 0.001). Ultrasound showed normal follicular development in 93 and 91% of patients after detorsion by laparoscopy and laparotomy respectively. At subsequent surgery, the adnexa appeared normal in nine out of nine patients after laparoscopy and in four out of five patients after laparotomy. Four patients of the laparoscopy group and two patients of the laparotomy group underwent subsequent IVF. In all six patients oocytes retrieved from the previously ischaemic ovary were fertilized. CONCLUSIONS: Detorsion with adnexal sparing is the treatment of choice for twisted ischaemic adnexa, and preferably performed by laparoscopy.

Laparoscopy versus laparotomy for detorsion and sparing of twisted ischemic adnexa.

BACKGROUND: Torsion of the ovary is an urgent event for fertile women. Until recent years, the common treatment for twisted ischemic ovaries was salpingo-oophorectomy. We have demonstrated in the past that the ovary can be salvaged provided detorsion is performed. We studied the outcome of women undergoing minimal surgery for ischemic ovaries versus the extended procedure including cystectomy in respect of ovarian function and fertility performance. METHODS: We retrospectively studied 102 women who underwent surgery for torsion of the ovary in which the macroscopic appearance of black-bluish ischemic adnexa was encountered during surgery. Detorsion without removal of the adnexa or the ovary was performed by laparoscopy in 67 patients and by laparotomy in 35 patients. Patients' files were reviewed for immediate and late outcomes. Patients were examined postoperatively with vaginal ultrasound for ovarian follicular function. Data concerning patients' further surgeries or in vitro fertilization were retrieved from the charts as well. RESULTS: Febrile morbidity was approximately 15% and 29% in the laparoscopy and laparotomy groups, respectively. Hospital stay was 2.1 +/- 1.2 and 7.4 +/- 1.5 days in the laparoscopy and laparotomy groups, respectively (P<0.001). Ultrasound follow-up was available in 60 of 67 patients who underwent laparoscopy and in 32 of 35 patients treated by laparotomy. Normal-sized ovaries with follicular development were encountered in the detorsed side in 93% and 91%, respectively. Normal macroscopic appearance of the adnexa at subsequent surgeries was reported in 9 of 9 patients in the laparoscopy group and in 4 of 5 patients in the laparotomy group. Four patients from the laparoscopy group and 2 from the laparotomy group underwent subsequent in vitro fertilization. In all 6 patients, oocytes retrieved from the previously detorsed ovary were fertilized. In both groups, none of the patients developed clinical signs of pelvic or systemic thromboembolism. CONCLUSIONS: Torsion of the ischemic adnexa should be treated laparoscopically by detorsion and adnexal sparing.

Giant uterine tumors: two cases with different clinical presentations.

BACKGROUND: Giant uterine tumors are uncommon. However, they may be life threatening because of pressure effects on the lungs and other adjacent organs. Proper surgical management and careful perioperative care are essential to assure a good outcome after excision. CASE: Two women with giant uterine leiomyomata (weighing more then 40 kg [88 lb]) are discussed. In one case the leiomyoma led to severe pulmonary hypertension and respiratory failure necessitating an emergency operation. Abdominal hysterectomy and bilateral salpingo-oophorectomy were successfully carried out in both cases, which are among the largest tumors ever removed with survival of the patient. CONCLUSION: Different clinical manifestations can be expected in cases of giant uterine tumors according to which other organs are secondarily affected. Numerous difficulties may be encountered in the evaluation and removal of these tumors. A combined team consisting of gynecologic, general, and plastic surgeons is necessary for a successful outcome.

Pregnancy outcome after laparoscopy or laparotomy in pregnancy.

STUDY OBJECTIVE: To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy. DESIGN: Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2). SETTING: Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals. PATIENTS: Three hundred eighty-nine pregnant women. INTERVENTION: Laparoscopy or laparotomy for various indications. MEASUREMENTS AND MAIN RESULTS: Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies. CONCLUSION: Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Diagnosis and treatment of heterotopic pregnancy compared with ectopic pregnancy.

STUDY OBJECTIVE: To compare the diagnosis and management of ectopic (EP) and heterotopic pregnancies (HP). DESIGN: Retrospective comparative study (Canadian Task Force classification II-2). SETTING: University tertiary referral center for endoscopic surgery. PATIENTS: Twelve women with HP and 210 women with laparoscopically confirmed EP. INTERVENTION: Laparoscopic treatment. MEASUREMENTS AND MAIN RESULTS: Among the 12 women with HP, all but 1 had received ovulation induction, 10 underwent in vitro fertilization-embryo transfer, and 1 conceived with clomiphen citrate. In the EP group 33 patients (15.7%) conceived spontaneously (p <0.05). Six women (50%) with HP had had previous pelvic surgery and three had a history of EP and salpingectomy. Four patients (33.4%) with HP and 29 (13.8%) with EP suffered from hypovolemic shock and required blood transfusion (p <0.05). Three of these four women with HP experienced physician and patient delays before admission. The sonographic diagnosis was correct in all women with HP and in 94.3% of women with EP. The median gestational age at diagnosis was 7.5 and 7.2 weeks for HP and EP, respectively. Six (50%) women with HP had evidence of fetal pulse in the ectopic gestation compared with 17 (8.1%) with EP (p <0.05). In addition, 66.7% and 24.7%, respectively, had ruptured tube (p <0.05). Mean +/- SD hemoperitoneum was 833.4 +/- 777 and 305 +/- 121 ml, respectively (p <0.05). Conversion to laparotomy was required in one (8.3%) and eight (3.8%) women, respectively (p <0.05). No major operative or postoperative maternal complications occurred in either group. Two women with HP had miscarriages, two have a continuing pregnancy, and eight delivered healthy newborns. CONCLUSION: Women with HP are at significantly greater risk for hypovolemic shock and requiring blood transfusion than those with EP. The diagnosis of EP in cases of HP is difficult due to the presence of an intrauterine gestational sac and hyperstimulated ovaries. A greater level of suspicion may allow early laparoscopic intervention before life-threatening intraabdominal bleeding has occurred.

Cervical Shirodkar cerclage may be the treatment modality of choice for cervical pregnancy.

BACKGROUND: Our objective was to evaluate the use of cervical suture in cervical pregnancy. METHODS AND RESULTS: All cases of cervical pregnancy diagnosed and treated in the gynaecological department at the Sheba Medical Center between 1994-2000 were included in the study. Eight such cases were diagnosed. The first four cases were treated medically. The last four cases (the study group) of cervical pregnancy, including one case of heterotopic pregnancy, were treated successfully with placement of Shirodkar cerclage. CONCLUSION: Cervical cerclage may be considered as the treatment of choice in cases of cervical pregnancies. It may be the only therapy in cases of heterotopic pregnancies (intrauterine and cervical pregnancy).