Abdominal myomectomy--a safe procedure in an ambulatory setting.

OBJECTIVE: To evaluate the efficacy and safety of minilaparotomy myomectomy in an ambulatory setting. DESIGN: Retrospective, nonrandomized study. SETTING: Center for Assisted Reproduction, Bedford, Texas. PATIENT(S): One hundred eighty-nine women desiring fertility with symptomatic uterine leiomyomata. INTERVENTION(S): Minilaparotomy myomectomy in an ambulatory setting. MAIN OUTCOME MEASURE(S): Operative time, blood loss, recovery time, postoperative analgesia, and complications. RESULT(S): The mean diameter of the largest leiomyoma was 4.4 cm (range, 1-14 cm). The mean number and weight of the leiomyomata was 4.9 (range, 1-35) and 109.8 gm (range, 1-1,165 g), respectively. The mean operative time was 73 minutes, and the mean blood loss was 96 mL. On average, patients required 3.5 hours of recovery time. In the recovery room, patients received a mean of 12 mg of morphine/37 mg of meperidine for pain control postoperatively before discharge home. Only one major complication, pulmonary edema related to extubation, occurred. CONCLUSION(S): This study demonstrates that minilaparotomy myomectomy, when performed using a systematic operative technique, can be accomplished in an outpatient setting with minimal blood loss, fast recovery time, and a low complication rate. Postoperatively, patients require minimal analgesia, which permits them to be discharged home the same day. Minilaparotomy myomectomy is a safe, cost-effective treatment of most symptomatic uterine leiomyomata in an ambulatory setting.

Gonadotropin releasing hormone antagonists suppress aromatase and anti-Müllerian hormone expression in human granulosa cells.

OBJECTIVE: To investigate the effects of a gonadotropin-releasing hormone antagonist (GnRH-ANT) on the expression of anti-Müllerian Hormone (AMH) and aromatase (via the exon CYP19IIa promoter), in cultured human granulosa cells (hGCs) and the human granulosa cell line (HGL5). DESIGN: Primary cell cultures of hGCs and culture of HGL5 cells. SETTING: Academic center. PATIENT(S): Women undergoing IVF because of male factor, tubal infertility, or donor eggs. INTERVENTION(S): hGCs and HGL5 cells were treated with a GnRH-ANT (1 nM and 1 µM) alone or in combination with cAMP (1 mM). Media was collected and stored at -80°C until assayed. MAIN OUTCOME MEASURE(S): mRNA levels of CYP19 IIa, AMH, steroidogenic factor 1 (SF-1) and liver receptor homologue-1 (LRH-1) were determined by quantitative polymerase chain reaction. ELISA was used to determined estradiol (E(2)) levels in the culture media. Pooled results from triplicate experiments were analyzed using one-way analysis of variance with Student-Newman-Keuls multiple-comparison methods. RESULT(S): The GnRH-ANT decreased the expressions of CYP19 IIa, AMH, SF-1, and LRH-1. cAMP induced aromatase and AMH expression. Cotreatment with cAMP and GnRH-ANT caused a dose-dependent suppression of AMH and CYP19 IIa mRNA. A GnRH agonist (GnRH-A) increased the mRNA expressions of CYP 19 IIa and AMH. The GnRH-ANT decreased E(2) production in cultured hGCs. CONCLUSION(S): GnRH-ANTs, in addition to their central suppressive effects on the pituitary, may have a direct effect on ovarian granulosa cells with inhibition of aromatase and AMH expression. Furthermore, the inhibitory effect could be mediated via suppression of SF-1 and LRH-1, and may play a role in estrogen-mediated ovarian folliculogenesis.

Heterotopic pregnancy after bilateral salpingectomy resulting in near-term delivery of a healthy infant.

OBJECTIVE: To describe an unusual case of heterotopic pregnancy. DESIGN: Case report. SETTING: Division of Reproductive Medicine and Infertility, Women & Infants' Hospital of Rhode Island, Brown Medical School. Providence, Rhode Island. PATIENT(S): A woman with an unusual heterotopic pregnancy who had had prior bilateral salpingectomies, but delivered a healthy female infant near term after requiring laparotomy for a ruptured left cornual pregnancy 28 days after embryo transfer. INTERVENTION(S): IVF, laparotomy with wedge resection of the left tubal cornu, and near-term cesarean section. MAIN OUTCOME MEASURE(S): Excision of ectopic pregnancy with preservation of intrauterine pregnancy. RESULT(S): Delivery of a 2920 gram (6 lb, 7 oz) female infant. CONCLUSION(S): Heterotopic pregnancy may occur after bilateral salpingectomy, but a satisfactory outcome can be obtained in such circumstances after surgical excision of the ectopic gestation and preservation of the intrauterine pregnancy.

The contribution of laminaria placement for cervical ripening in second trimester termination of pregnancy induced by intra-amniotic injection of prostaglandin F(2)alpha followed by concentrated oxytocin infusion.

OBJECTIVE: Our purpose was to determine whether intracervical placement of laminaria stalks would improve the effectiveness of inducing termination of pregnancies in the second trimester by intra-amniotic injection of prostaglandin F(2)alpha. STUDY DESIGN: This is a prospective randomized clinical trial conducted at Gynecology Department, Lis Maternity Hospital. Fifty women admitted for indicated second trimester pregnancy termination were randomly assigned to receive either intracervical placement of laminaria (n = 25) or not (n = 25), with concurrent use of intra-amniotic injection of prostaglandin F(2)alpha and concentrated oxytocin. The outcome measures were: time from induction to delivery and the side effects and complications of treatment. RESULTS: There was no significant difference in the mean interval from induction to delivery in the laminaria and no laminaria groups, being 20 +/- 1.3 (8-30) h versus 19 +/- 1.0 (8-26) h, respectively. In addition, this interval was not different in subgroups of primiparas or multiparas. Other outcome measures such as retained placenta (4% in both groups), post-partum hemorrhage (4% in both groups) gastro-intestinal side effects, fever, and use of analgesia were not significantly different between both groups. CONCLUSION: We found no additional value in placing laminaria stalks when using intra-amniotic injection of prostaglandin F(2)alpha followed by concentrated oxytocin infusion for second trimester termination of pregnancy.