Cornual polyps of the fallopian tube are associated with endometriosis and anovulation.

Background. The relationship between tubal cornual polyps and endometriosis and ovulatory disorders in infertile women is unclear. Our objective was to determine such an association from our database and review the literature. Methods. Twenty-two infertile women with tubal cornual polyps were assessed for coexistence of oligoovulation/anovulation and endometriosis with stratification for polyp diameter (large: ≥5 mm diameter, small <5 mm diameter). Result(s). Oligoovulation/anovulation was more prevalent in women with large versus small tubal cornual polyps (P = 0.0048). Endometriosis was associated with both large and small polyps. Conclusion(s). This case series confirms the association of tubal cornual polyps with oligoovulation/anovulation and endometriosis in infertile women. This case series is limited by a lack of controls.

Role of laparoscopic salpingostomy in the treatment of hydrosalpinx.

OBJECTIVE: To determine pregnancy rates after laparoscopic salpingostomy in occlusive distal tubal disease. To evaluate the relative impact of various historical, physical, and operative factors on pregnancy outcome using a multivariate statistical analysis. DESIGN: Prospective cohort. SETTING: University-affiliated tertiary care infertility clinic. PATIENT(S): One hundred thirty-nine infertile women with occlusive distal tube disease. INTERVENTION(S): Laparoscopic salpingostomy. MAIN OUTCOME MEASURE(S): The occurrence of intrauterine (IUP) and ectopic pregnancy (EP). RESULT(S): The overall IUP and EP rates were 24.5% and 16.5%, respectively. Analysis of historical variables, assessed independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions. CONCLUSION(S): Operative laparoscopy may be effective for the correction of hydrosalpinges in selected patients. The probability of achieving an intrauterine or an ectopic pregnancy can be predicted based on combinations of significant variables.

Crohn's disease and tubal infertility: the effect of adhesion formation.

The purpose of this paper was to assess the management of tubal disease in women with Crohn's disease. We are presenting a case series describing four patients with Crohn's disease who were treated at a tertiary infertility clinic within an university hospital. Fertility investigations and appropriate therapy plans in these patients with Crohn's disease who also had tubal infertility are outlined. The clinical outcome in all four cases demonstrated interference with the management and surgical therapy of the tubal infertility by extensive adhesion formation. We conclude that adhesion formation complicates the investigation and surgical therapy of patients with Crohn's disease.

Ovarian cyst formation and congenital absence of the inferior vena cava: case report.

Congenital absence of the inferior vena cava (IVC) is a rare condition that presents clinically as recurrent venous thromboses and leg ulcers. We report an association with painful ovarian cysts in a 25 year old woman. The possible pathophysiology and unique management issues posed by this case are presented.

Heterotopic pregnancy complicating in vitro fertilization.

A review was undertaken of the cases of heterotopic pregnancy resulting from in vitro fertilization/embryo transfer (IVF/ET) and frozen embryo replacement (FER) in a 6-year cohort of women at National Women's Hospital in Auckland. The incidence of heterotopic pregnancy was 2.9% (5 cases) in 173 clinical pregnancies resulting from 901 embryo replacements. Of the 5 women with heterotopic pregnancy, 1 had unilateral tubal patency and 4 had bilateral tubal blockage; 3 had 'high responder' peak serum oestradiol levels (greater than 9,000 pmol/L) prior to oocyte pick-up (OPU); 3 had a serum human chorionic gonadotrophin beta subunit (beta-HCG) level greater than 600 IU/L on Day 14 following embryo transfer (ET) in the absence of a multiple intrauterine gestation on subsequent ultrasound scan. In the 4 women in whom unequivocal diagnosis of heterotopic pregnancy was not made on the initial ultrasound scan, there was delay in appropriate management, in 1 for more than 5 months. In conclusion, early IVF pregnancies require a transvaginal ultrasound scan performed by a sonographer experienced in the diagnosis of ectopic pregnancy and management of early pregnancy complications by clinicians in close consultation with the IVF centre itself. No single risk factor, laboratory test or combination of these is sensitive or specific enough to predict the occurrence of heterotopic pregnancy. The first-line surgical treatment of heterotopic pregnancy should be laparoscopic salpingectomy with excision of all except the intramural portion of the affected Fallopian tube.

Simplified therapy for Asherman's syndrome.

OBJECTIVE: To evaluate a technique that converts a blind hysteroscopic procedure to a "septum" division. DESIGN: Open noncomparative clinical study. SETTING: Tertiary care center. PATIENT(S): Six women with Asherman's syndrome; five with complete and one with incomplete obliteration of the uterine cavity. INTERVENTION(S): The patients underwent recreation of the uterine cavity by the hysteroscopic-laparoscopic technique described to establish the correct dissection plane. MAIN OUTCOME MEASURE(S): The ability to reestablish the uterine cavity; postoperative resumption of menses and fertility. RESULT(S): In all patients, the cavity of the uterus was restored; menses resumed in all women who were previously amenorrheic; and 5 women conceived, of whom four had live births and one a missed abortion. At hysteroscopy, two women incurred perforations and in another hemorrhage occurred. CONCLUSION(S): This technique appears to be effective and safe for the reconstruction of a functional endometrial cavity in women with Asherman's syndrome.

Laparoscopic lateral ovarian transposition.

OBJECTIVE: To determine if the new technique laparoscopic lateral transposition of the ovaries before pelvic radiotherapy for anal canal carcinoma prevents radiation-related ovarian failure. DESIGN: A case report. SETTING: The operating room of a Canadian teaching hospital. PATIENTS: A single patient with anal canal carcinoma, requiring pelvic radiotherapy, who desired preservation of ovarian function. INTERVENTIONS: Laparoscopic ovarian transposition to the level of the pelvic brim. MAIN OUTCOME MEASURES: Follow-up clinical and laboratory evidence of ovarian failure. RESULTS: Initially ovarian failure was confirmed with the appearance of postmenopausal symptoms and the elevation of serum gonadotropins. These symptoms resolved by 8 months after radiotherapy, normal menstrual cycles resumed, and normal FSH levels were detected at that time. CONCLUSIONS: The laparoscopic, lateral transposition of this patient's ovaries was effective at preventing radiation-related ovarian failure.

Laparoscopic oophoropexy for recurrent adnexal torsion.

Torsion of the adnexa has traditionally been treated by adnexectomy because of the fear of emboli departing from thrombosed ovarian veins. Several recent reports have described successful conservative management with unwinding of the twisted adnexa. As the trend toward conservative management progresses, the incidence of recurrent adnexal torsion may increase. We present a case of a 33 year old gravida 3, para 2 Caucasian female who presented at 7 weeks gestation complaining of symptoms similar to those experienced during an episode of right ovarian torsion treated by laparoscopic unwinding 6 years earlier. Colour Doppler sonography revealed absent flow in the right adnexa. The twisted right adnexa containing the presumed corpus luteum of pregnancy was laparoscopically unwound. Using an extracorporeal suturing technique, a laparoscopic oophoropexy was performed to prevent any further rotatory movement. This appears to be the first reported case of laparoscopic oophoropexy for a recurrent ovarian torsion; we encourage the use of this simple, minimally invasive procedure in cases of recurrent adnexal torsion.

A new selection criterion for fimbriectomy reversal.

OBJECTIVE: To assess a new criterion for selection of patients who request reversal of fimbriectomy sterilization. DESIGN: Prospective study. SETTING: Division of reproductive endocrinology and infertility in an academic center. PATIENTS: Eight patients undergoing reversal of fimbriectomy using microsurgical techniques. The prerequisite inclusion criterion was the presence of more than 50% ampulla as shown at hysterosalpingography. This is easily determined, because the isthmic length approximates one half the ampullary length. RESULTS: The cumulative intrauterine pregnancy rate was 50%. There were no ectopic pregnancies. CONCLUSION: Similar pregnancy rates for reversal of fimbriectomy have been reported based upon different absolute selection criteria (viz., tubal length of > or = 8 cm and ampullary width of > or = 1 cm). By contrast, our new selection criterion is based upon the more readily determined proportion of ampulla that is available for surgical neostomy.

Predictors of success of reversal of sterilization.

OBJECTIVE: To determine the prognostic variables effecting the successful pregnancy outcome of reversal of sterilization. DESIGN: Demographic and clinical history data were collected prospectively. SETTING: Division of Infertility and Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada. PATIENTS AND INTERVENTION: Between 1981 and 1992, 217 consecutively referred patients underwent reversal of sterilization by a single surgeon using microsurgical techniques. MAIN OUTCOME MEASURES: Prognostic variables associated with success were examined using logistic regression and expressed as odds ratios with corresponding 95% confidence intervals. RESULTS: Age at reversal was a significant factor with the odds of a successful outcome for those < or = 35 years compared with those > 35 years being 2.3 with a 95% confidence interval of 1.3 to 4.1. There was some evidence that average tubal length as categorized in 2-cm intervals was a significant prognostic factor with the odds of a successful outcome for those with an average length of > 4 cm to those < or = 4 cm being 5.3 with a 95% confidence interval of 1.4 to 20.0. CONCLUSIONS: Nonsubjective analysis of the prognostic variables of reversal of sterilization associates only age and tubal length of > 4 cm with intrauterine pregnancy.

PIP: This study was designed to determine which prognostic variables influence the successful pregnancy outcome of reversal of sterilization. The study is prospective, pertains to a single surgeon with the exclusive use of the microscope, uses nonsubjective grouping of prognostic factor categories, and examines the power of the study to detect clinically meaningful associations. Over the period 1981-92, 217 consecutively referred patients underwent reversal of sterilization by a single surgeon using microsurgical techniques. Logistic regression found age at reversal to be a significant factor, with the odds of a successful outcome for those aged 35 and younger compared with those older than 35 being 2.3 with a 95% confidence interval of 1.3-4.1. There was some evidence that average tubal length as categorized in 2-cm intervals was a significant prognostic factor, with the odds of a successful outcome for those with an average length of more than 4 cm to those less than or equal to 4 cm being 5.3 with a 95% confidence interval of 1.4-20.0. Nonsubjective analysis of the prognostic variables of the reversal of sterilization therefore associates only age and tubal length of more than 4 cm with intrauterine pregnancy.

Removal of the ovarian surface epithelium from the rabbit ovary--a cause of adhesions following a standard injury.

To assess the effect of the removal of ovarian surface epithelium on repair, a standard injury was induced in the ovaries of 10 rabbits. In one ovary the surface cells were denuded, and in the other they were left intact. The effect on adhesion formation was assessed at 12 days. Adhesions were assessed by visual inspection at laparotomy and histological examination of adhesion formation, including a stereological assessment of scar volume. On visual assessment the overall adhesion scores for the denuded ovaries were greater than for the intact ovaries. Histology showed the adhesions were attached only to the site of injury. The Fallopian tube was adherent to 35 and 4% of the denuded and intact ovarian segments respectively (P = 0.003). The scar volumes for each side were similar. After 12 days there was only partial re-epithelialization on the denuded ovaries. Electron microscopy confirmed the slow healing, with much of the surface still covered by a fibrinous-like exudate. The findings of this small study lend further weight to the importance of the surface epithelium in the control of adhesion formation. Standard surgical procedures may generate adhesions by the inadvertent denuding of surface epithelium from adjacent healthy tissues, possibly by the loss of plasminogen activator activity that is found in the mesothelium of the peritoneum. This study highlights the importance of controlling for inadvertent cell loss whilst investigating methods for adhesion prevention.

Evaluation of the sites of ectopic pregnancies subsequent to reconstructive tubal surgery.

The sites of ectopic pregnancies in women who underwent various types of reconstructive tubal surgery were analysed and compared to the controls. Overall, ectopic pregnancies subsequent to all types of tubal surgeries were more often implanted proximally compared to the control population.

The ascites in the ovarian hyperstimulation syndrome does not originate from the ovary.

OBJECTIVE: To evaluate the direct ovarian contribution to ascites formation in the ovarian hyperstimulation syndrome (OHSS) in a rabbit model. DESIGN: Prospective experimental study. SETTING: Research center of a university teaching hospital. PARTICIPANTS: New Zealand White rabbits. INTERVENTIONS: Both ovaries of the rabbits in the experimental group were enclosed within a pouch developed from the surrounding peritoneum and mesosalpinx by microsurgery. Animals in the control group did not undergo any surgical intervention. Ovarian hyperstimulation was induced by alternate day equine chorionic gonadotropin and intermittent human chorionic gonadotropin (hCG). MAIN OUTCOME MEASURES: Degree of ascites formation and the morphological and endocrinologic signs of ovarian hyperstimulation. RESULTS: The serial plasma estradiol and progesterone levels, ovarian weights, and ascites response were not statistically different between the two groups. CONCLUSIONS: Isolation of both ovaries from the peritoneal cavity does not prevent ascites formation in the OHSS. Increased transudation across extraovarian serosal surfaces contributes to ascites formation in OHSS.

The effect of intraovarian injection of oxytocin and vasopressin on ovulatory function and numbers of ovarian follicles.

Our findings support the clinical use of vasoconstrictor solution within the ovary to achieve hemostasis. This will allow the gynecologist to avoid the thermocoagulative injury to the ovary by replacing electrosurgery and laser surgery with sharp incision accompanied by vasoconstrictor injection.

A new suturing instrument that allows the use of microsuture at laparoscopy.

PIP: A surgeon at University Hospital-Shaughnessy Site in Vancouver, British Columbia in Canada has used a new suturing instrument that enters the peritoneal cavity to permit microsutures of size 6-0 or less and 75 cm in length during laparoscopy. Surgeons can use this instrument to perform female sterilizations as well as removal of the gall gladder and appendix and repair of the bowel, bladder, and ureteric injuries. As of April 1992, the suturing instrument was not yet commercially available. It consists of a partial hollow 30 cm x 2 mm (inside diameter) tube with the end that does not enter the peritoneal cavity being occluded. The suturing instrument enters the peritoneal cavity via a standard 5 mm deflection valved trocar sleeve with a 3 mm reduction sleeve or with a 3 mm inside diameter occlusive rubber washer instead of the standard 5 mm washer. The suture must have sufficient tensile strength and have low coefficients for static and for sliding surface frictions. Once the suture and needle are inside the body, forceps which have entered via another cannula detach them from the suturing instrument. A 3 mm laproscopic needle driver replaces the suturing instrument at this point. The surgeon guides the needle through the intended tissues and then withdrawn with the needle driver through the 5 mm sleeve. The surgeon ties the knot outside the body and slides it down the length of the suture to apply it to the tissue. He/she repeats this 1 more time. Scissors inserted through the other opening then cut the suture. Once mastered, this process takes only a few minutes to complete. In all 11 cases or restoration of uterine tube patency done by the surgeon in Vancouver using the new technique, tubal patency has not been hindered. 2 assessed sterilization reversals have been successful.^ieng

Midtubal occlusion: etiology, management, and outcome.

OBJECTIVE: To assess the significance of pathological midtubal occlusion in infertility. DESIGN: Retrospective descriptive case review. SETTING: Tertiary referral center. PATIENTS: Sixteen women, 26 to 38 years of age presenting with infertility and diagnosed as having midtubal occlusion. INTERVENTIONS: Assessment of the etiology of the occlusive disease and yield of microsurgical tubotubal anastomosis. MAIN OUTCOME MEASURES: Histologic examination of occluded tubal segment and fertility outcome subsequent to anastomosis. RESULTS: Occlusion was because of tuberculous salpingitis (n = 6), resolved tubal pregnancy (n = 3), endometriosis (n = 2), chronic inflammatory reaction (n = 1), tubal cyst (n = 1), intratubal adhesions (n = 1), infant hernia repair (n = 1), and calcification (n = 1). Of eight women (including the patient with tuberculous salpingitis) who underwent tubal anastomosis only for midtubal occlusion, three had subsequent term deliveries, two had tubal pregnancies, and three women did not conceive. CONCLUSION: Midtubal occlusion of the tube because of an infectious process is rare. Excluding tuberculous salpingitis, microsurgical anastomosis yields satisfactory fertility, albeit with significant risk of ectopic pregnancy.

Free autologous graft of fimbria to ampulla with subsequent oviductal function in the rabbit.

To test the hypothesis that a free, nonvascularized graft of fimbria would retain structure and function, fimbriae were transplanted autologously in 17 rabbits. Subsequently, the transplanted fimbrial tissue survived, with patency in almost all the animals, was capable of transporting surrogate cumulus oophorus but had reduced ovum capture capability. That the transplanted rabbit fimbria retains a degree of structure and function suggests that the technique warrants an investigation in women.

The intussusception salpingostomy technique for the therapy of distal oviductal occlusion at laparoscopy.

A new technique of salpingostomy by laparoscopy for treatment of distal oviductal occlusion is described. This technique uses sharp dissection and can be performed rapidly. The intussusception salpingostomy is undertaken by making a relatively short incision in the hydrosalpinx and then prolapsing the tubal mucosa through this neostium. The borders of the incision thus act as a restrictive collar to maintain the mucosa in this newly everted configuration. In a series of 40 women subjected to this procedure, 22 were followed for more than 12 months postoperatively; the term pregnancy rate was 22.7%. This fertility is similar to that after salpingostomy by microsurgical laparotomy.