Adenomyoma and leiomyoma: differential diagnosis with transvaginal sonography.

PURPOSE: The purpose of this study was to evaluate the capability of transvaginal sonography to differentiate adenomyomas from leiomyomas. METHODS: Two hundred six patients scheduled for surgery for symptomatic uterine masses underwent preoperative transvaginal sonography. Sonographic findings were compared with pathologic findings. Pathologic findings showed that 111 patients had leiomyomas, 48 had diffuse adenomyosis, 31 had adenomyomas, and 4 had leiomyosarcomas. RESULTS: For the diagnosis of adenomyoma, transvaginal sonography demonstrated a sensitivity of 82.0%, specificity of 88.3%, positive predictive value of 84.6%, and negative predictive value of 87.5% compared with a sensitivity of 95.1%, specificity of 82.0%, positive predictive value of 90.7%, and negative predictive value of 85.7% for the diagnosis of leiomyoma. Two sonographic characteristics, lesion margin (p = 0.0001) and lacunae (p = 0.0001), allowed the differentiation of adenomyoma from leiomyoma. CONCLUSIONS: Transvaginal sonography is an effective procedure for the preoperative differentiation of adenomyoma from leiomyoma. If the status of the lesion's margins and the presence or absence of hypoechoic lacunae were selected for analysis, leiomyomas could be correctly diagnosed with transvaginal sonography in 95% of cases.

Genuine stress incontinence: prospective randomized comparison of two operative methods.

Eighty-one women with clinical and urodynamic findings of genuine stress incontinence and genital prolapse were randomly selected to be surgically treated with either anterior colporrhaphy or Burch colposuspension. Each patient had a complete clinical and urodynamic evaluation before surgery and at 2 months and 3 years after surgery. Differences in cure rates between the two procedures at the 2-month post-operative evaluation were insignificant; however, at the 3-year post-surgical evaluation, the cure rate of women who had undergone Burch colposuspension was significantly higher than that of women who had undergone anterior colporrhaphy (cure rates were 88% and 57%, respectively; P < 0.001). The Burch colposuspension was more effective than the anterior colporrhaphy in the stabilization of the bladder base, neck and proximal urethra as confirmed by transvaginal sonography. Post-operative spontaneous voiding was uneventful in both procedures. Results of this study demonstrate that the Burch colposuspension in our hands was more effective in treating genuine stress incontinence and pelvic relaxation than was anterior colporrhaphy.

Ovarian surface serous papillary carcinomas: a clinicopathologic study.

Between 1982 and 1992, 129 patients with malignant epithelial ovarian tumors were reviewed with identification of 10 patients having surface papillary serous carcinoma of the ovary and one having peritoneal papillary carcinoma. The gross operative specimens, histopathologic condition, and treatment records were reviewed. All patients had disease involving the omentum, and the abdominal and pelvic peritoneum, and they all corresponded to stage III, according to FIGO. The median age at presentation was 58-years (age range, 43 to 73 years). All patients had a total abdominal hysterectomy and bilateral salpingo-oophorectomy, and all received chemotherapy. The median survival time for all patients was 15 months. Three patients are alive 3 to 4 years after the initial diagnosis. In conclusion, surface serous ovarian cancers and peritoneal papillary serous cancers have common histologic appearance and the same responsiveness to surgical therapy and to chemotherapy and should be treated similarly.

Active corpus luteum function at pre-, peri- and postimplantation is essential for a viable pregnancy.

Luteal-phase estrogen and progesterone concentrations were measured every other day and used to monitor the corpus luteum activity. The patterns of estrogen and progesterone concentrations were compared relative to the day of endogenous human chorionic gonadotropin (hCG) detection (defined as the day of implantation). The relationship between estrogen and progesterone and hCG concentrations was studied in 71 viable pregnancies, 12 clinical abortions, five preclinical abortions and 84 non-pregnant cycles after IVF/ET. Although all patients received luteal-phase progesterone support (25-50 mg/ml), low late luteal-phase progesterone concentrations of < 30 ng/ml from day + 11 to day + 15 were found in 64 patients (17% of viable pregnancies, 33.3% of clinical abortions, 60% of preclinical abortions and 53.6% of non-pregnant cycles) day + 1 was the day of retrieval). Implantation always occurred before or on day + 13 and 86% of pregnant cycles implanted on day + 8 to day + 11. Viable pregnancies had significantly higher mean progesterone concentrations on day + 3 to day + 7 (pre-implantation) and on day + 9 to day + 15 (postimplantation) than those of non-pregnant cycles or abortions. On the day of implantation, the mean +/- standard of deviation of estrogen (pg/ml) and progesterone (ng/ml) levels for viable pregnancies, clinical abortion and preclinical abortions were 314 +/- 210, 40.5 +/- 25; 226.7 +/- 246, 48.7 +/- 31; and 39.6 +/- 24.5, 28.6 +/- 24.5, respectively. On the same day, 73.2% of viable pregnancies, 41.7% of clinical abortions, and 20% preclinical abortions had a progesterone concentration > 30 ng/ml; 73.2% of viable pregnancies, 41.7% of clinical abortions and 20% of preclinical abortions had an estrogen concentration > 100 pg/ml. Although not precluding implantation completely, late luteal-phase hormonal deficiencies may impair endometrial growth and might ultimately lead to failure or abnormal implantation. A viable pregnancy requires not only a functional corpus luteum in the early luteal phase to develop a receptive endometrium, but also a responsive corpus luteum in the late luteal phase to support pregnancy. The time of implantation is critical. Implantation that occurs before the demise of the corpus luteum will facilitate a normal pregnancy.

Sonographic incidence of polycystic ovaries in a gynecological population.

The prevalence of polycystic ovaries in a large population of 1078 women of reproductive age was determined by pelvic ultrasonography. The ovarian ultrasonic appearance of 183 (17%) women met the morphological criteria of polycystic ovaries. Of these women, 147 (80.3%) had irregular cycles (group A) and 36 (19.7%) had normal cycles (group B). The remaining women constituted the control group. Ovarian volume was calculated in all women in whom at least one ovary was visualized. Serum levels of luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone were measured in 124 women from group A, 25 from group B and 50 controls. Mean ovarian volume was statistically higher in both group A (13.4 ml) and group B (11.8 ml) than in the control group (6.2 ml). Mean LH/FSH ratio and mean testosterone values were statistically higher in group A only (2.1 and 1.1 ng/ml, respectively) compared with the mean values in the control group (0.7 and 0.7 ng/ml, respectively). Obesity and hirsutism were more common in group A than in group B and the controls. Screening the ovaries in women of reproductive age and subsequent assessment of morphology in polycystic ovaries can aid in the diagnosis of this condition in patients who may have a varied clinical presentation.

Fallopian tube sperm perfusion has no advantage over intra-uterine insemination when used in combination with ovarian stimulation for the treatment of unexplained infertility.

In this prospective randomized study we treated 60 couples with unexplained infertility with a combination of ovarian stimulation and either intrauterine insemination (IUI) or fallopian sperm perfusion (FSP). In the IUI we used a volume of 0.5 ml of inseminate and in the FSP a volume of 4 ml. The demographic characteristics of the patients, the stimulation parameters and the sperm data were not statistically different between the two groups. The pregnancy rate per cycle was 16.2% in the IUI group and 14.5% in the FSP group and the pregnancy rate per woman was 40 and 36.7%, respectively (not statistically different). We conclude that IUI and FSP are equally effective in the treatment of couples with unexplained infertility.

Ectopic pregnancies after in vitro fertilization and embryo transfer.

OBJECTIVE: Our objective was to analyze the risk factors, stimulation characteristics, and future fecundity of patients with ectopic pregnancies after in vitro fertilization (IVF). METHODS: We retrospectively evaluated all cases of ectopic pregnancy occurring between January 1989 and March 1993 (Cornell series 1 to 17). A case-control group of intrauterine pregnancies was used for comparison of the stimulation and transfer characteristics. RESULTS: Twenty-seven of 1123 pregnancies (2.4%) were ectopic, following 2812 fresh IVF embryo transfers, while 8 of 105 pregnancies (7.6%) were ectopic, following 405 frozen-thawed embryo transfers. Tubal factor was the cause of infertility in the majority (85.7%) of ectopic pregnancies. No difference was found between the ectopics and the matched controls in stimulation and transfer characteristics. Thirty ectopic pregnancies were ampullary, two were interstitial, two were cervical, and one was heterotopic. Twenty of the patients subsequently underwent 29 IVF attempts, with a pregnancy rate of 41.4% per transfer. CONCLUSIONS: Ectopic pregnancy after IVF appears to be related to preexisting tubal pathology; embryo transfer of cryopreserved thawed embryos in a natural cycle may result in a higher ectopic rate in these patients; in subsequent IVF cycles the intrauterine pregnancy rate of these patients is not decreased.

CA 125 in preoperative evaluation of pelvic masses.

Serum CA 125 levels were measured preoperatively in 126 women subjected to laparotomy due to palpable pelvic mass. Forty out of 42 patients with true malignant serous ovarian carcinoma had serum CA 125 levels higher than 35 U/ml. Among 62 patients with some types of gynecologic malignancy, 48 also met the cutoff value of 35 U/ml. Sensitivity, specificity, positive and negative predictive value of CA 125 as a tumor marker, proved to be satisfactory. These results suggest that CA 125 assay can be used as a diagnostic adjunct in the preoperative evaluation of patients with a pelvic mass.

Comparison between metal cup and silicone rubber cup vacuum extractor.

A total of 400 primiparous patients who were delivered by vacuum extractor were studied. The patients were divided in two groups: Group A included 200 patients who were delivered by metal cup vacuum extractor and Group B consisted of 200 patients who were delivered by rubber cup vacuum extractor. There were no statistically significant differences in the mean maternal age, mean gestational age, mean neonatal birth weight, indications for operative delivery, occipital positions and head stations between the two groups. No differences were found in the rates of birth canal trauma (11% vs. 12.5%), major neonatal scalp trauma (6.5% vs. 5.5%), neonatal jaundice (15.5% vs. 13.5%) and Apgar score. From this study we can conclude that both metal and silicone cups are equally satisfactory for vacuum extraction.

Cystic hygromas associated with Turner's syndrome. Report of three cases.

Three cases of cystic hygromas are reported. Two of these were singleton pregnancies diagnosed at 20 weeks' gestation and the other was an affected fetus in a twin pregnancy at 19 weeks gestation. Amniocentesis was done and chromosomal analysis revealed Turner syndrome in all cases. The two singleton pregnancies were terminated by intrauterine installation of PgF2a. The affected fetus of the twin pregnancy died at 24 weeks' gestation and the pregnancy continued.

Vaginal sonography of the endometrium in postmenopausal women.

The purpose of this study was to compare transvaginal ultrasound scanning and histology of the endometrium obtained by curettage. One hundred twenty women with postmenopausal bleeding were examined by vaginal sonography, before undergoing curettage. Endometrial thickness, as measured by vaginal sonography, was used as an indicator of endometrial abnormality. The mean endometrial thickness in those women with endometrial cancer was 16.6 +/- 5.4 mm as compared with 3.2 +/- 1.1 mm in those women with atrophic endometrium, and 9.5 +/- 2.3 in those with hyperplasia. If a cutoff limit of 5 mm had been used in this study, 82% of the curettage procedures could have been avoided, without missing a single case of serious endometrial pathology. We conclude that vaginal sonography is a reliable examination in the detection of endometrial abnormality in women with postmenopausal bleeding.

Maternal serum cortisol and prolactin variations during labor.

Maternal serum cortisol (F) and prolactin (PRL) levels were measured during labor in 20 uncomplicated pregnancies. Four pregnant women were admitted with ruptured membranes (RM group) and 16 were admitted with intact membranes (IM group), ten with spontaneous onset of labor (SL group) and 10 with induced labor (IL group), five with a prolonged for duration labor (PL group) and 15 with a normal for duration labor (NL group). Before the inset of labor F levels were statistically higher (p less than 0.05) in the RM group (x = 975 ng/ml), than in the IM group (x = 664 ng/ml), and also in the SL group (x = 783 ng/ml), than in the IL group (x = 679 ng/ml). During labor, in all twenty pregnant women a marked rise of F (from x = 726 ng/ml before the onset of labor, to x = 911 ng/ml) and a marked fall of PRL (from x = 161 ng/ml to x = 122 ng/ml) were observed (p less than 0.05). In the PL group the F elevation and the PRL drop were more pronounced (p less than 0.001). After placental separation, PRL levels increased slightly while F values remained unchanged. These changes in hormone levels before and during labor could be attributed to the emotional and physical stress of labor.