Ovarian stromal echogenicity in women with clomiphene citrate-sensitive and clomiphene citrate-resistant polycystic ovary syndrome.

OBJECTIVE: To compare stromal echogenicity in women with clomiphene citrate (CC)-sensitive and CC-resistant polycystic ovary syndrome (PCOS), and to compare stromal echogenicity before and after laparoscopic ovarian drilling in women with CC-resistant PCOS. DESIGN: Prospective study. SETTING: University teaching hospital. PATIENT(S): Twenty-two infertile women. INTERVENTION(S): Transvaginal ultrasound examination and laparoscopic ovarian drilling. MAIN OUTCOME MEASURE(S): Ovarian stromal index (ratio of mean ovarian stromal echogenicity to mean echogenicity of the entire ovary). RESULT(S): The mean (+/- SD) ovarian stromal index was 1.26+/-0.27 in the women with CC-sensitive PCOS and 1.22+/-0.11 in the women with CC-resistant PCOS. The ovarian stromal index and ovarian volume of the women with CC-resistant PCOS before and after ovarian drilling were not significantly different. CONCLUSION(S): There was no difference in the stromal index and ovarian volume between women with CC-sensitive PCOS and women with CC-resistant PCOS. There was no overall difference in the stromal index and ovarian volume in women with CC-resistant PCOS before and after ovarian drilling.

Endoscopic myomectomy. Laparoscopy and hysteroscopy.

There is a place for both laparoscopy and laparotomy in the surgical management of patients with uterine myoma. The surgeon's expertise in laparoscopic suturing is a crucial requirement for laparoscopic myomectomy. Hysteroscopic myomectomy is the best treatment of women with submucous myoma.

Adhesion-related small-bowel obstruction after gynecologic operations.

OBJECTIVE: Our purpose was to evaluate a possible relationship between adhesion-related small-bowel obstruction and gynecologic operations. STUDY DESIGN: The records of all female patients with the diagnosis of small-bowel obstruction from 1989 to 1996 were studied. The cause of bowel obstruction, the type and technique of previous operations, and whether the parietal peritoneum was closed at the completion of the procedure or was left open were evaluated. RESULTS: Among 262 women the most common cause of small-bowel obstruction was intra-abdominal adhesions (37.0%). Among 92 women with adhesion-related small-bowel obstruction, 35 women (38%) had undergone a previous abdominal hysterectomy. The incidence of small-bowel obstruction after an abdominal hysterectomy was 16.3 per 1000 hysterectomies. The incidence of small-bowel obstruction after cesarean delivery (5/10,000 cesarean deliveries) was significantly less than after other abdominal operations. Adhesions were found between the small bowel and the pelvis in 14 women (29.8%), and all were in women who had undergone a hysterectomy. In 33 others (70.2%) the adhesions were found between the previous abdominal incision and the intestine. The median interval between the initial operation and the small-bowel obstruction was 5.3 years. CONCLUSION: The most common cause of small-bowel obstruction is postsurgical adhesions. Adhesionrelated small-bowel obstruction is commonly found after an abdominal hysterectomy. Bowel obstruction can occur many years after the initial abdominal surgery.

A study of nerve fibers and histopathology of postsurgical, postinfectious, and endometriosis-related adhesions.

OBJECTIVE: To evaluate the presence of nerve fibers and histopathology of endometriosis-related adhesions, postsurgical adhesions, and postinfectious adhesions in women with and without pelvic pain. METHODS: We evaluated the presence of nerve fibers and histopathology of endometriosis-related adhesions, postsurgical adhesions, and postinfectious adhesions in 50 women. The nerve fibers were identified by immunocytochemistry staining with an antibody to neurofilament. RESULTS: Nerve fibers were found in the intraabdominal adhesions in 39 of the total 50 patients with such adhesions (78%). There was no significant difference in the proportion and the mean nerve score in adhesions due to previous intra-abdominal infection, endometriosis, and previous uninfected intra-abdominal surgery. The degree of lymphocytes and edema in endometriosis-related adhesions was significantly higher than in postsurgical adhesions and postinfectious adhesions (P < .05). No difference was found in the amount of nerve fibers and the mean nerve score in adhesions from women with pelvic pain and from those without pelvic pain. CONCLUSION: Nerve fibers are found commonly in intraabdominal adhesions, and their presence are not related to the underlying pathology or pelvic pain. Endometriosis-related adhesions contain more inflammatory cells and tissue edema than postsurgical or postinfectious adhesions.

Laparoscopic ovarian suspension before irradiation.

OBJECTIVE: To evaluate a technique of lateral ovarian transposition by laparoscopy. DESIGN: Case report. SETTING: Tertiary care center. PATIENT(S): A 34-year-old woman with rectal carcinoma. INTERVENTION(S): Laparoscopic ovarian transposition. MAIN OUTCOME MEASURE(S): Return of normal menstruation after irradiation. RESULT(S): Lateral ovarian transposition could be done by laparoscopy. However, division of the ovarian ligament was needed. The location of the ovaries after surgery was outside the radiation field. CONCLUSION(S): Lateral ovarian transposition can be done by laparoscopy. Contrary to a previous report, division of the ovarian ligament is required.

Reproductive outcome after treatment of mild endometriosis with laparoscopic excision and electrocoagulation.

OBJECTIVE: To compare the pregnancy rates (PRs) of infertile women with mild endometriosis treated laparoscopically by surgical excision and by electrocoagulation. Laparoscopic treatment of minimal and mild endometriosis usually is done by laser or electrocoagulation. Whether surgical excision is associated with similar results is unknown. DESIGN: Retrospective study with a historical control. SETTING: University teaching hospitals. PATIENT(S): One hundred one infertile women undergoing laparoscopic treatment of mild endometriosis. INTERVENTION(S): Forty-eight women were treated with electrosurgery (historical control) and 53 women were treated with excision. MAIN OUTCOME MEASURE(S): The PRs of the two groups of women were evaluated using life-table calculations and the Mantel-Cox test. RESULT(S): Of the total 24 pregnancies (PR: 57.1%) in the electrosurgery group, there were 3 spontaneous abortions (12.5%) and 1 ectopic pregnancy (4.2%). The total PR in the excision group was 53.5%, the abortion rate was 17.4% (4 of 23), and the ectopic PR was 8.7% (2 of 23). The median interval between surgery and conception was 10.7 months in the electrosurgery group and 13.3 months in the excision group. There was no statistically significant difference in the probability of conception between the two groups of women (Mantel-Cox test: z = 0.24). Using the Cox proportional-hazards model, the effects of age and duration of infertility were evaluated and were found not to be associated with a decreased PR. CONCLUSION(S): There is no difference in the PRs of infertile women with mild endometriosis treated laparoscopically by surgical excision and by electrocoagulation. The difference between these two modalities in women with endometriosis-related pelvic pain remains to be determined.

Effects of pirfenidone and dermoid cyst fluid on adhesion formation.

OBJECTIVE: To evaluate the effects of pirfenidone and human dermoid cyst fluid on adhesion formation in a rat model. DESIGN: A prospective, blinded, controlled study. SETTING: Sprague-Dawley white rats in a conventional laboratory setting. INTERVENTION(S): Rats were divided into four groups according to the type of solution tested (dermoid fluid, 0.05 mg of pirfenidone, normal saline, and a combination of dermoid fluid and pirfenidone). In the first experiment, the solution (0.5 mL) was injected intraperitoneally. In the second experiment, the solution was instilled intraperitoneally after a standardized injury to the right uterine horn. The degree of adhesion formation was evaluated 2 weeks after the initial surgery. RESULT(S): Human dermoid cyst fluid caused adhesion in 4 of 10 intact rats and in 9 of 10 standardized injured rats. Pirfenidone did not decrease adhesion formation. No adhesion was found after injection of saline or pirfenidone in intact rats. The mean +/- SEM adhesion score in standardized injured rats was higher in the dermoid group (4.6 +/- 0.6) than in the pirfenidone group (2.8 +/- 0.7) or the saline group (3.8 +/- 0.5). The mean +/- SEM adhesion score in intact rats was 0.6 +/- 0.3 after dermoid fluid injection and after dermoid instillation in standardized injured rats was 4.6 +/- 0.6. CONCLUSION(S): Human dermoid fluid causes adhesion formation even in intact rats, and the adhesion is worse in the presence of serosal injury. Intraperitoneal pirfenidone does not decrease adhesion formation.

Surgical management of polycystic ovarian syndrome.

The objective of this chapter is to review the role of surgical management of polycystic ovarian syndrome in infertile women. Pertinent studies and their references were identified through computer medline search. To date there is no standardization of the technique of laparoscopic ovarian drilling. However, it appears that the results are promising, with a high ovulation rate ranging between 70% and 90% and a pregnancy rate of 70%. Clomiphene citrate remains the first line of treatment to induce ovulation in infertile women with polycystic ovarian syndrome. Laparoscopic ovarian drilling can be offered to clomiphene-resistant women, especially to those who have also failed to respond to gonadotrophin treatment or who have experienced ovarian hyperstimulation syndrome. It appears that the pregnancy rate after ovarian drilling is comparable with that for gonadotrophin therapy. However, until more complete and long-term data are available, caution must be exercised when offering this type of treatment.