Ethanol endometrioma sclerotherapy: safety through 8 years of experience.

STUDY QUESTION: What are the complications of transvaginal ethanol sclerotherapy for the treatment of endometriomas? SUMMARY ANSWER: Sclerotherapy is a reliable, minimally invasive method applicable in outpatient procedures but with specific and potential life-threatening complications that need to be identified and prevented. WHAT IS KNOWN ALREADY: There are currently few data on the use of transvaginal ethanol sclerotherapy, and we mainly note septic complications. STUDY DESIGN, SIZE, DURATION: A retrospective observational cohort study was carried out. The study was conducted at an academic hospital and included 126 women aged 31.9 ± 5.5 years (mean ± SD), between November 2013 and June 2021. We analyzed a total of 157 ethanol sclerotherapy treatment (EST), treated by 131 EST procedures, in 126 women. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study included women with an indication for transvaginal ethanol sclerotherapy. Indications were women with at least one endometrioma over 10 mm, isolated or associated with other endometriosis locations, requiring treatment for pain or infertility before assisted reproductive treatment. We followed a standardized transvaginal ethanol sclerotherapy procedure consisting of an ultrasound-guided transvaginal puncture of one or more endometriomas under general anesthesia. The cyst content was completely removed and flushed with saline solution. Ethanol (96%) was injected at 60% of the initial volume of the endometrioma, remained in the cyst for 10 min and was then completely removed. Ethanol loss was defined as a loss of 5 ml or more than 10% of the initial volume of the injected ethanol. Failure was defined by the contraindication of endometrioma puncture because of interposition of the digestive tract, ethanol loss in the previous endometrioma treated (in case of multiple ESTs), failure to aspirate the endometriotic fluid, contraindication to start ethanol injection owing to saline solution leakage, or contraindication to continue ethanol injection owing to suspicions of ethanol leakage at sonography. Intraoperative complications were defined by ethanol loss, positive blood alcohol level, and ethanol intoxication. Postoperative complications were defined by fever, biological inflammatory syndrome, and ovarian abscess. Complications were classified according to the Clavien and Dindo surgical classification, which is a system for classifying postoperative complications in five grades of increasing severity. MAIN RESULTS AND THE ROLE OF CHANCE: We reported a total of 17/157 (10.8%) transvaginal ethanol sclerotherapy failures during 14/131 (10.7%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. In the same sets of data, complication was reported for 15/157 (9.5%) transvaginal ethanol sclerotherapy in 13/131 (9.9%) transvaginal ethanol sclerotherapy procedures in 13/126 (10.3%) women. Nine of 126 women (7.1%) had a grade I complication, one (0.8%) had a grade II complication (medical treatment for suspicion of pelvic infection), two (1.6%) had a grade III complication (ovarian abscess) and one (0.8%) had a grade IV complication (ethanol intoxication). We did not observe any grade V complications. LIMITATIONS, REASONS FOR CAUTION: This was a retrospective study and pain assessment not considered. The benefit-risk balance of endometrioma transvaginal ethanol sclerotherapy was not evaluated. WIDER IMPLICATIONS OF THE FINDINGS: Our study is the first to evaluate the complications of transvaginal ethanol sclerotherapy with such a large cohort of women in a standardized protocol. Transvaginal ethanol sclerotherapy seems to be an effective alternative to laparoscopic surgery in the management of endometriomas and limits the alteration of ovarian reserve. Transvaginal ethanol sclerotherapy is a reliable, minimally invasive method applicable on an outpatient basis. The majority of complications are Clavien-Dindo ≤IV, for which preventative measures, or at least early diagnosis and treatment, can be easily performed. The risk of ethanol intoxication is rare, but it is a life-threatening risk that must be avoided by appropriate implementation and promotion of the sclerotherapy procedures. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: Aix Marseille University's ethics committee registration number 2021-06-03-01.

[Management of endometriomas in France: A survey of practices]. / Prise en charge des endométriomes en France : enquête de pratiques.

OBJECTIVES: To present an overview of French practices for the management of endometriomas. METHODS: We carried out a nationwide survey of practices concerning the management of endometriomas between October 2021 and January 2022. This study was carried out by means of two questionnaires sent to surgical centers used to treat endometriosis (n=62) and to Assisted Reproductive Technology (ART) centers (n=102). RESULTS: At the end of the survey, 39/62 (62.9%) surgical teams from the centers contacted had given a response and 51/102 (50.0%) from ART centers. Laparoscopic cystectomy was the technique most frequently used by almost two thirds of the surgical teams (61%) when there was no known infertility, whereas it was the most common technique for only 14% of the ART teams. On the contrary, ultrasound-guided sclerotherapy was the most frequent technique for more than half of the ART teams (56%) and for only 8% of the surgical teams. In case of recurrence, 49% of surgical teams would choose ultrasound-guided sclerotherapy. Prior to IVF, 73% of ARP teams stated that they 'rarely' treated endometriomas. CONCLUSION: The results of our study show a certain variability in practices between different centers and depending on the presence or absence of infertility for the management of endometriomas in France.

Initial experience with vNOTES hysterectomy for benign conditions in a French university hospital.

Background: Natural orifice transluminal endoscopic surgery by the vaginal route (vNOTES) is a new approach to performing hysterectomy. Clinical outcomes must be evaluated in centres that have started performing this technique. Objectives: To compare operative outcomes between vNOTES hysterectomy and laparoscopic hysterectomy during the introduction of the vNOTES approach in a teaching hospital. Material and Methods: A retrospective study was conducted from November 2019 to May 2021 at a French academic hospital in Marseille. The included patients underwent total hysterectomy for benign indications by vNOTES or conventional laparoscopy. Main outcome measures: Operative time, uterus weight, intraoperative complications, and postoperative complications according to the Clavien-Dindo classification. Results: Eighty-six patients underwent hysterectomy according to the selected criteria: 36 procedures were performed by vNOTES and 50 by laparoscopy. The mean operative time was shorter in the vNOTES group than in the laparoscopy group [116 min versus 149 min; p=0.003]. The mean uterus weight was not different between the vNOTES group and the laparoscopy group (238g versus 281g; p=0.572). Laparo-conversion occurred in one case in the vNOTES group (2.7%) and three cases in the laparoscopy group (3.4%). One Grade III postoperative complication occurred in the laparoscopy group, and no severe complication occurred in the vNOTES group. Conclusion: Operative outcomes of the vNOTES hysterectomy were favourable and support good feasibility without additional morbidity compared to laparoscopy. What is new?: During the introduction period of the vNOTES hysterectomy technique in a teaching hospital, reassuring operative outcomes and a low rate of complications were observed.

[Embryotoxic factors and recurrent spontaneous abortions]. / Facteur embryotoxique et interruptions spontanées répétées de grossesse.

About 30% of recurrent spontaneous abortions remain unexplained by traditional or biological anomalies. The purpose of this work was to investigate embryotoxic factors produced by trophoblast stimulated lymphocytes from women with unexplained recurrent spontaneous abortion. The samples from 36 women with recurrent abortion before and during the next pregnancy and from 7 women with normal pregnancies and no history of spontaneous abortion have been tested. The lymphocytes were stimulated with trophoblastic extracts. The supernatants of the stimulated lymphocytes were tested in a 4-cell mouse embryo culture. The secretion of embryotoxic factor was determined if the number of life blastocysts was less than 50% of control values after 4 days. The lymphocytes from 59% women with 3 or more recurrent abortion produced the embryotoxic factor, this factor may be useful in predicting pregnancy outcome in women with a history of unexplained recurrent miscarriage. The embryotoxic factor might be a new cause of recurrent abortion and a predictive factor.

[Reccurent abortions: unpublished syndrome suggesting the explanation of fetal death]. / Avortements à répétition: un syndrome inédit suggérant l'explication de la mort foetale.

A report is given of 8 cases of recurrent "idiopathic" abortions sharing in common the following features, unreported so far: (1) high uterine arterial impedance; (2) decrease in endometrial thickness, in spite of normal hormonal and endometrial cycle at biopsy; (3) a history of previous curettages. Such a syndrome could be consistent with the existence of a narrow peripheral symphysis of the uterine cavity, unaffecting its shape at hysterography.

A simple and inexpensive treatment of menopause: prophylaxis of postmenopausal bone loss.

Relatively few women elect to receive classical hormone replacement therapy (HRT), and others discontinue treatment because of side-effects or fear of complications. This report presents the results of a long-term study of a low-dose step-down HRT protocol and discusses its potential benefits.

No evidence for the expression of the progesterone receptor on peripheral blood lymphocytes during pregnancy.

The expression of the progesterone receptor in human peripheral blood lymphocytes was analysed, using an enzyme linked immunosorbent assay (Abbott PgR-EIA monoclonal), in order to evaluate its prognostic character in the context of spontaneous abortion. Cytosols were prepared from lymphocytes of 24 healthy pregnant women (11 first, 10 second and three third trimester), seven healthy non-pregnant women, nine women with recurrent spontaneous abortion, and six healthy men. In addition, a human breast carcinoma cell line (ZR-75-1), which expresses the progesterone receptor, was analysed throughout. The ZR-75-1 cell line showed an expression of 642 fmol/mg whereas lymphocytes of pregnant women showed an expression < or = 4 fmol/mg. Lymphocytes of non-pregnant women, women with threatened pre-term delivery, and men showed equivalent levels: 3 +/- 1, 3 +/- 2 and 5 +/- 4 fmol/mg respectively. These results show that there is no evidence of specific expression of the progesterone receptor in pregnancy and exclude any prognostic character in spontaneous abortion. A role for the progesterone receptor in the mechanism of the known effect of progesterone on peripheral blood lymphocytes is also excluded.

HLA antigen-sharing in couples with repeated spontaneous abortions and the birthweight of babies in successful pregnancies.

Previously, several groups reported an increase in HLA antigen-sharing in couples suffering from unexplained repeated spontaneous abortions. It was felt necessary to find out if HLA sharing could have any effect on children born after a successful pregnancy. The birthweight figures of children of 76 couples with repeated spontaneous abortions were analyzed. The results show a significantly lower birthweight in babies born from those couples, presenting a high incidence of HLA antigen-sharing, particularly concerning class II antigens.

[Effect of decapeptyl (D-TrpG GnPh) on estrogen receptors, progesterone receptors and tissue levels of estrogens (non-conjugated and sulfate-conjugated) in patients with uterine myoma]. / Action du décapeptyl (D-Trp6GnRH) sur les récepteurs oestrogeniques, les récepteurs de la progestérone et sur la concentration tissulaire d'oestrogènes (non-conjugués et sous forme sulfate) chez des patientes atteintes de fibrome utérin.

Concentrations of estrogen receptors, progesterone receptors, unconjugated estrogens (estradiol and estrone) and sulfate-conjugated estrogens (estradiol sulfate and estrone sulfate) were determined in patients treated with Decapeptyl and in controls. After prolonged Decapeptyl therapy, a highly significant fall in progesterone receptors was evidenced; estrogen receptors were found to be decreased in the myoma as compared with the secretory phase in controls and in the myometrium as compared with the proliferative phase in controls. Tissue levels of estrone sulfate and estradiol sulfate decreased very substantially. In conclusion, Decapeptyl emerges as a very promising agent for the treatment of uterine myomas.

Effect of Decapeptyl, an agonistic analog of gonadotropin-releasing hormone on estrogens, estrogen sulfates, and progesterone receptors in leiomyoma and myometrium.

Estrogens (estrone [E1] and estradiol [E2]), their sulfates and progesterone receptor (PR) were evaluated in patients with uterine leiomyomata nontreated and treated with Decapeptyl (D-Trp6-gonadotropin-releasing hormone [GnRH]; Ipsen Biotech, Paris, France). Estrogen concentrations are very high in the leiomyoma (secretory phase, pg/g tissue [mean +/- SEM]: n = 10; E1: 147 +/- 24; E2: 850 +/- 116; E1-sulfate: 1,668 +/- 808; E2-sulfate: 718 +/- 126). Decapeptyl treatment provokes a significant decrease in E2 and particularly in E1 and E2 sulfates. Progesterone receptors were higher in the leiomyoma than in the myometrium; after a long treatment (3 to 4 months) a significant decrease in both tissues is observed. The decrease provoked by D-Trp6-GnRH on estrogens (unconjugated and sulfates) and in PR in the leiomyoma after long treatment, supports the hypothesis that estrogens are implicated in the cause of these tumors.

[Follicular ovarian cysts appearing during progestin or estroprogestin oral contraception at low doses]. / Les kystes folliculaires ovariens apparaissant lors de la contraception orale progestative ou oestroprogestative à faibles doses.

PIP: 2 cases of functional ovarian cysts are described to illustrate an increasingly common but little studied complication of progestin-only or phasic oral contraceptives. A 20-year-old woman without previous pathology who had used a pill containing .35 mg norgestrienone for 6 months suddenly developed violent lower abdominal pain. Sonography revealed a mass that was believed to result from extrauterine pregnancy, and surgery was performed. In the 2nd case, a 39-year-old woman taking a triphasic containing levonorgestrel and ethinyl estradiol had unexplained lumbosacral pain. Sonography again revealed an ovarian cyst. The triphasic was discontinued and the cyst disappeared over the next several days. A review of the literature suggested that such cysts are common but only about 1 in 6 are painful. They appear to result from the inhibition of pituitary luteinizing hormone by the progestin while follicle stimulating hormone secretion persists. Follicular secretion of estraiol may or may not reach significant levels. The complication should be known by physicians because the pain and adnexal mass should not be mistaken for a surgical emergency. Oral contraceptive package inserts should indicate that functional ovarian cysts may occur in women using progestin or phasic pills.^ieng

Methodical intrauterine resection.

A technique using a fine intrauterine resectoscope with mobile electrical loop and continuous flow providing a thoroughly clear vision in all circumstances was used to resect 61 submucous leiomyomas. This technique allows complete resection of intrauterine benign tumours such as submucous leiomyoma sessile type partially embedded in the myometrium, old and wide marginal synechiae, or uterine septa. Under direct visual control it allows one to perform deep biopsies leading to precise histologic diagnoses with determination of possible myometrial penetration. The advantages of this technique, which may be performed eventually on outpatients with paracervical block, are: precise hemostasis; complete and controlled uterine evacuation, avoiding postoperative infections; precise histologic diagnosis; suppression of a good percentage of hysterectomies and open myomectomies; simplicity of follow-up; brevity of hospitalization and convalescence, which are sometimes nil; and conservation, or even restoration, of fertility.

Effect of zinc administration on plasma testosterone, dihydrotestosterone, and sperm count.

The effects of zinc therapy on plasma testosterone (T), dihydrotestosterone (DHT), and sperm count were studied in 37 patients with idiopathic infertility of more than five years duration. In the first group (T less than 4.8 ng/ml; 22 patients), T and DHT rose significantly after oral administration of zinc, as did the sperm count. Nine wives became pregnant, six within 3 months and three within 2 months of a second trial. In the second group (T greater than or equal to 4.8 ng/ml; 15 patients), T and sperm count were unaffected by zinc, while DHT increased significantly. There was no conception observed. The rationale of this treatment and the significance of the results are discussed.